Offline: The incontestable moral value of health

Abstract

In March, 2020, chief science advisers from 12 countries, including the US, the UK, and Germany, issued a call to scholarly publishers “to voluntarily agree to make their COVID-19 and coronavirus-related publications, and the available data supporting them, immediately accessible in PubMed Central and other appropriate public repositories.” That same month, over 30 publishers, including The Lancet, signed up to this request. The call reflected the urgency of the pandemic and “the associated global health crisis.” We have made all of our coronavirus-related content freely available through a COVID-19 Resource Centre. But why stop with a pandemic? Are there not other global health crises that would benefit from immediate access to new scientific findings? Where should one draw the line in deciding what scientific information is instantly and freely available? And who should draw that line? The pandemic has accelerated massive change in scientific publishing. Preprints of COVID-19-related research papers are now routinely posted. On balance, preprints have been a positive step forward for science. Immediate access to new, although non-peer-reviewed, results has been helpful for policy makers, journalists, and a public eager to devour every new discovery. Occasionally, there has been unscrupulous behaviour. Some institutions have issued press releases publicising preprints in ways that have given too much credence to provisional findings. But my concern isn’t with preprints or even with this pandemic. My unease lies with the arbitrary criteria for defining a “global health crisis” and so the capricious justifications for denying immediate access to new research findings. Isn’t AIDS an urgent global health crisis? Or any one of an array of non-communicable diseases ravaging socially excluded and poor communities? Debates about access to scientific research usually and quickly devolve into disputes about the merits of open access mandates. Or the material contributions society publishers make to the disciplines they champion. Or the benefits commercial publishers bring to the wider economy. Sometimes, important principles are enunciated—publicly funded research must be publicly accessible. But none of these arguments cuts through to what I think is the crucial distinction this pandemic has revealed—that health and health research have a special moral importance to society, an importance that should demand zero tolerance to any barrier limiting access to healthcare and health information. The philosopher Norman Daniels put forward a compelling case for the special moral importance of health in his 2008 book, Just Health. The “fundamental question” he posed was, “As a matter of justice, what do we owe each other to promote and protect health in a population and to assist people when they are ill or disabled?” Part of his answer was to establish the obligations we have to promote and secure health, obligations that do not apply to other goods. Daniels’ claim is that health is of special moral importance because protecting health—keeping people functioning normally by meeting their health needs—protects the opportunities open to us. By opportunities, Daniels means “the array of life plans reasonable persons are likely to develop for themselves.” Poor health diminishes those fair opportunities. Daniels based his argument on John Rawls’ theory of justice. Rawls claimed there could be no justice without fair opportunities for all. Justice demands the protection of those fair opportunities. If, therefore, fair opportunity is a crucial dimension of justice, and if those opportunities depend on health, then justice must give a special moral place to health. Daniels defines health needs as adequate nutrition; sanitary, safe, unpolluted living and working conditions; healthy lifestyles; medical services; social care; and “an appropriate distribution of other social determinants of health”. To these, I would add reliable health information, which provides the basis for any high-quality health system. The post-COVID-19 challenge for scientific editors is to address the reasoned claims that health and health research are foundational components of a just society, that health and health research occupy positions of special moral importance to that society, and that journal editors have a responsibility to advocate for the removal of all access barriers to the results of scientific research. There is no logical or ethical basis for designating COVID-19 a special case. The argument for immediate access to new health research findings is a straightforward matter of justice, not expediency. It's time for editors to say so clearly and forcefully.