A Republican Egalitarian Approach to Bioethics: The Case of the Unrecognized Bedouin Villages in...

Republican Egalitarian Approach to Bioethics

International Journal of Health Services, July 6, 2015, doi: 10.1177/0020731415594601

A Republican Egalitarian Approach to Bioethics: The Case of the

Unrecognized Bedouin Villages in Israel

Dani Filc1, Nadav Davidovitch

2, Nora Gottlieb

2

1Department of Politics and Government, Ben-Gurion University of the Negev,

Beer Sheva, Israel

2Department of Health Systems Management, Ben-Gurion University of the

Negev, Beer Sheva, Israel

Introduction

The emergence of bioethical thinking is related to the universalization of

individual human rights, among other things as a reaction to the First and

Second World War and the Holocaust (1-5). Most thinkers who reflect on the

links between human rights, the right to health and bioethics do so within a

liberal framework, which informs both their conceptualization of the right to

health and their way of thinking about bioethics (6-8). The present paper poses

an alternative perspective linking a republican egalitarian conceptualization of

bioethics with a radical egalitarian grounding of the right to health. Such

perspective will go beyond the liberal emphasis on individual autonomy and

freedom as non-interference, considering the right to health as socially

grounded.

Following this understanding, the present paper analyzes the possibilities of

going beyond the traditional bioethical approach through the analysis of a



specific case-study: water policies towards the Bedouin population living in

“unrecognized villages” in southern Israel. The paper opens with a radical

egalitarian definition of the right to health; it goes on to discuss how such

definition can inform a conceptualization of bioethics that goes beyond the

tenets of liberalism; and it exemplifies such conceptualization by applying it to

the field of public health ethics, using the above mentioned case-study.

The right to health: liberal vs. radical egalitarian perspectives

The UNESCO 2005 Declaration on Bioethics and Human Rights stresses the

close relation between human dignity, human rights and bioethics (3, 9). The

declaration aims to integrate a bioethical analysis into the human rights

framework (4). Such integration is made possible, as several scholars state (4,

10-13), by the common emphasis on individual autonomy and on a liberal-

individualistic conceptualization of rights (9). Much of the existing literature

on the right to health, too, is guided by the same liberal approach (14-19).

From this perspective, the right to health is considered mainly as an individual

right, belonging to the juridical sphere and subject to juridical review (8).

When discussing questions of entitlement in the field of health and health care,

liberal approaches stress aspects related to civic and individual rights, among

them mainly the right to bodily integrity, autonomy, consent, individual right

to health care and the quid pro quo between the right to health care and

property rights (6, 7, 20-23). Liberal approaches tend to accept inequality as a

given (19). Even liberal egalitarians such as Daniels, accept a certain degree of



inequality, not only as given but as a necessity, arguing that "our concern for

equality must be reconciled with considerations of liberty and efficiency"

(24:366, see also 17).

Moreover, liberal egalitarians understand equality as equality of opportunity.

Veatch, in his exposition of the liberal egalitarian perspective on the right to

health care, claims that "justice requires that persons be given an opportunity

to have equal health status insofar as possible" (19:83). Daniels, on his part,

argues that equality of opportunity is violated "only if unfair social practices

or preventable or curable diseases or disabilities interfere with the pursuit of

reasonable plans of life… [, thus] making us lose competitive advantage. We

accept… the fact that the natural distribution of talents and skills, working in

an efficient market for them, will both enhance the social product and lead to

inequalities in social outcomes" (24:366).

However, if we accept the claim that "everyone's life is equally important"

(25:22) and the basic idea that all persons are of equal worth, then the liberal

egalitarian perspective is not enough. Under such assumptions we cannot

accept avoidable inequalities in health as a given or a necessity. The idea of all

people having equal moral worth – central to the liberal, the democratic and

the socialist tradition – can be truly fulfilled only in a society in which persons

stand in relations of equality (26); in a society which aims "to provide the

social basis for an equality of condition for all human beings" (27:7, emphasis

in the original). Thus, we need a conceptualization of the right to health

coherent with the idea of equality of condition.



Another problem of many of the current framings of the right to health is that

they understand the latter as the right to health care (17, 24, 28), even though

we know that the contribution of health care services to the population’s health

is relatively limited (29, 30). An extensive body of research on the social

determinants of health has shown that variables related to social structures

such as poverty, education, working conditions, nutrition, housing, water

quality, or discrimination play a key role in determining our health status (30).

A thorough elaboration of an alternative definition of the right to health

exceeds the scope of the present paper (for a broader discussion see, for

example, Filc (31)). However, we do want to offer here what we consider to

be a radical egalitarian definition of the right to health – a definition in which

equality is understood as equality of condition, and that accounts for the social

determinants of health. From such perspective, the right to health means that

every person has a claim to the amount of goods and services - including

health care – that are needed to ensure a level of health equal to that of any

other person, when inter-individual differences in health are the product of

social organization or can be reduced by treatment; and every person has a

claim to equal health care for equal needs in those cases in which inter-

individual differences in health result from natural – biological – variations, or

from personal choices when those choices are not determined by the unequal

distribution of resources and power. (See Whitehead (32) for a clarifying

classification of the causes of disparities in health.) Instead of focusing on the



individual and on personal autonomy, a radical egalitarian health rights

approach will stress the importance of social structures, and the need for a

different institutional framework that works towards making a universal right

to health possible. Such approach also emphasizes the centrality of politics in

building adequate institutions and in modifying those social structures that

cause inequities in health.

In this formulation, following Sen (33), health is understood as the physical

and psychosocial status which allows for the full development of each person's

capabilities, and as the absence (or significant diminution) of suffering, pain

and disability. Understanding health and the right to health in the terms

articulated above has consequences for bioethical thinking.

Beyond liberal bioethics: A republican egalitarian perspective:

Mainstream bioethical thinking (especially in its US version), which was first

epitomized in the Belmont Report, is part of the liberal tradition. It considers

individual autonomy as central, having lexical priority over the principles of

non-maleficence, beneficence and justice. Having developed historically from

medical ethics, the dominant conception of bioethics concentrates mainly on

the individual and on health care. A focus on the individual, lack of criticism

of the context in which choices are made and the absence of consideration of

unequal distribution of power and resources still characterize dominant

bioethical thinking, especially in the US (see, for example, Grady (34)). This



approach has aroused criticism and calls for bioethicists to take into account

the social context and the unequal distribution of resources and power that

frame peoples’ lives and health (35-37). Even liberal philosophers like Daniels

have criticized the individualistic myopia of mainstream bioethical thinking,

which does not examine "the broader institutional settings and policies that

mediate population health" (38:23).

A radical egalitarian understanding of the right to health as presented in the

previous section requires a novel type of bioethical thinking. The centrality of

equity and the attention to the structural causes of ill health and their political

character cannot be addressed by mainstream liberal bioethics. We suggest

that a republican egalitarian perspective provides us with a conceptual

framework that helps illuminate those aspects that remain obscured by the

liberal focus on the autonomous individual. Adopting a republican perspective

implies moving from a clinical ethics approach to genuine public health ethics,

which takes into account that individuals’ and communities’ health are shaped

by social structures and institutions. (European bioethicists have explored

alternative paths to the liberal individualist one. Holm (35) argues for a strong

beneficence principle. More in line with the ideas explored in the present

paper, Hayri (48) puts forward the idea of solidarity and the fact that

individuals are always socially embedded. However, while mentioning

Aristotle and Marx, he does not present the concept of solidarity as part of a

more general alternative to the liberal worldview.)



It is widely accepted to consider the republican approach as being represented

by two main currents: a) a neo-Aristotelian one, which stresses the importance

of self-government and political participation (39); and b) a civic republican

current (40, 41) that stresses freedom as non-domination (42). Though an in-

depth discussion of republicanism clearly exceeds the limits of the present

paper, the directions posed in the present paper belong mainly to the first

current. Building on Dagger (43) we consider the following as the main

characteristics of a republican egalitarian perspective on bioethics: 1) political

equality in the sense that "[e]veryone… should have the opportunity to

become a citizen, and every citizen should stand on an equal footing, under

law and in the political arena…" (43:174, emphasis added). This means that

republicanism requires "steps to be taken to relieve women from subjection to

men, workers from subjection to employers, and the members of some racial,

ethnic or cultural groups from subjection to others" (43:174). Political

equality, that is, the possibility to equally participate in governing the political

community, as Rousseau (44) argued, requires limiting material inequalities.

(This last point is not common to all current strands of neo-republicanism,

since some thinkers such as Pettit (40) do not see the value of material

egalitarianism for its own sake.) As such, political equality is both a value in

itself and the necessary basis for the following two central characteristics: 2)

freedom as self-government. Citizens must be free from the arbitrary rule by

others and must (be able to) participate in the legislation of the laws that

oblige them; and 3) the possibility of a politically achieved conception of the



common good; that is, a conception of the common good that has been agreed-

upon through free and equal participation in the public sphere (43).

We propose that the ideas of a politically constituted common good, reciprocal

responsibility and self-government offer fresh perspectives on the problems

that arise from a sole emphasis on considering autonomy as individual free-

choice (see, for example, Glick (45)).

The idea of individual autonomy, which is central to liberal political

philosophy, is strongly linked to understanding freedom as the absence of

external interference (46, 47). The republican conception poses a different

understanding of individual actions in considering individual agents as shaped

by social institutions. For republicanism, relations between individuals are

rooted in the way power is organized within society (39). In this interpretation

of the republican tradition, freedom implies not only respect for individual

autonomy, but also collective action aimed at modifying unequal and unjust

concentrations of power in order to allow self-government and political

equality (39). Autonomy, in the republican tradition, is not freedom of choice

of the individual consumer whose wants are always sovereign; but as self-

government, which implies also the balance between individuals’ desires and

interests and the common good. Such balance is always political in that it is

negotiated between all the members of the political community. Moreover,

from a republican perspective the principle of autonomy has no lexical priority

over other bioethical principles such as non-maleficence, beneficence, justice



or solidarity. The relations between the different principles result from

negotiation. Hence, the principle of beneficence (as well as the principle of

non-maleficence) can be understood not in its original and paternalistic

version (where the physician or the researcher knows and decides on behalf of

the patient what beneficence is), nor in an individualistic consumer version

(where the "client" decides what s/he considers as of benefit). On the contrary,

it must be understood as a decision grounded in the negotiated, collective

framing of a common good. The principle of justice is understood as social

justice and substantial equality, described by Rousseau as a precondition for

equality under the law, as the latter is only possible "insofar as they all have

something and none of them has anything superfluous" (44:58). It becomes

central in guiding decisions on a “just” (re)distribution of power and

resources. The principle of solidarity reflects the "fundamental social

embeddedness of individuals" (48:204).

Adopting a republican approach to bioethics that is grounded on a radical

egalitarian understanding of the right to health does not only mean to modify

the way we understand the principles of bioethics; but it also significantly

expands the scope of bioethics from individual cases to social issues and

brings into focus the politics of power. It thus broadens the ethical discussion

and moves it into the realm of genuine public health ethics as an ethics that

addresses not only the individual, autonomous patient but the complex

relationships between the individual, civil society, social groups, social

institutions and the state (49).



Towards a republican egalitarian public health ethics: the Case of the

Unrecognized Bedouin Villages of the Negev

An analysis of Israel’s current water policies towards the unrecognized

Bedouin villages in South Israel is useful to illustrate the possibilities that a

republican egalitarian approach, grounded on the above exposed definition of

the right to health, affords to bioethics. Access to an adequate amount of water

of good quality is a key social determinant of health (30). Having defined the

right to health as the claim every person has to the amount of goods and

services that are necessary to provide a level of health equal to that of any

other person, it is thus clear that equal access to water is part of the right to

health. From this perspective it is the state's obligation to ensure availability,

accessibility and quality of water for all persons under its governance. It has to

do so in an equitable manner and with special attention to marginalized

groups.

More equitable access to water has the potential to reduce the global burden of

disease and help reduce health inequality. For example, better access to water

alone could reduce the global prevalence of diarrheal diseases and trachoma

by 25% (50). However, many problems in water supply are the result of

human action such as pollution or inequitable distribution (51, 52). In

particular, the growing scarcity of water and socio-political decisions such as

the privatization of water resources jeopardize the chance for better water

accessibility for all (53, 54). The Human Development Report 2006 states that



many times “scarcity is manufactured through political processes and

institutions that disadvantage the poor” (52:3). Also political and social

conflicts play out on water distribution when the party in power abuses access

to water as leverage against other population groups.

The “unrecognized” Bedouin villages (UBVs) of the Negev area in South

Israel existed prior to the establishment of the State of Israel. Due to a conflict

over land ownership the Israeli government does not consider the UBVs as

legal settlements and refuses to provide them with basic infrastructure such as

electricity, running water and connection to the sewage system. The

authorities' logic of non-recognition aims to make the Bedouin population

move to government-planned townships in order to reduce the space that the

Bedouin communities occupy in the area. The question of land ownership

overshadows all planning processes related to the UBVs, overwriting other

professional and moral considerations such as health, education, urban

planning or environmental protection (55).

Half of the Bedouin population of the Negev area, approximately 85,000

persons, lives in 35 UBVs. The villagers are the weakest socio-economic

group in Israeli society (56). In 2013, the fertility rate among the Bedouin

population was 5.38 compared to 2.92 among the local Jewish population;

more than 60% of the population is below the age of 17 years. Infant mortality

rates are up to threefold higher than those of the local Jewish population (11.2

and 3.9 respectively in 2013) (57, 58). Apart from the lack of electricity,



running water and sewage, social services such as health and education are

hardly available (59).

Water is considered a common good in Israel (60, 61). In the Israeli water

economy, the Israeli Water Commission is responsible for the implementation

of the water policy determined by the Ministry of Infrastructure. Mekorot, a

government-owned company, is the main water supplier. Most of the Israeli

population enjoys safe potable water. However, a different water economy

system applies to the UBVs. In order to receive water supply, a minimum of

ten families have to jointly apply to a special Water Committee. The

committee is made up of representatives of institutions such as the police, the

Israeli army, and the Ministry of Interior. Neither the Ministry of Health

(MOH) nor the communities are represented and decision-making processes

are not made transparent (60, 61). Between 2003 and 2006, 86% (180) of all

applications were denied, following the committee's respective

recommendations (60). The current water policy towards the Bedouin

residents of the UBV is sustained by their exclusion from decision-making

processes, as their perspectives and local knowledge are considered subjective

and irrelevant for policy-making (62), and since the institutions regarded as

legitimate representatives by the villagers such as the Regional Council for the

Unrecognized Villages of the Negev are themselves unrecognized by the state

(55).

To date, there are approximately 300 central water points of 1 inch/2.54 cm in

diameter in the UBVs. Each point is shared by an average of 250 persons and



their livestock. The respective households' average water consumption is 100

liters per day compared to 170-350 liters per day in the Jewish towns of the

Negev (63). The water points are up to 8 kilometers from the homes, which

makes them inaccessible according to WHO standards (64). The families

themselves are responsible for establishment and maintenance of individual

connections from the central water points to their homes. Pipelines are laid on

the ground; the water becomes boiling hot in summer and freezes in winter.

More than half of the UBVs' residents do not have a water point. They travel

long distances two to three times a week to wait for hours in line in order to

fill containers at a filling point at high costs. The containers may be exposed to

the sun for days. The water becomes hot, turbid, and ridden with algae and

rust. Eventually, many families are required to get water also from unchecked

sources such as wells (63). As a consequence of the lack of running water and

the constraints on getting water from other sources, the residents of the UBVs

are forced to excessively limit their water consumption.

Under the current arrangement, the institutions of the Israeli water economy

are responsible only for the central water points. Responsibility for individual

connections and water quality at household level is shifted to the families.

Such arrangement discriminates against the inhabitants of the unrecognized

villages and exacerbates inequalities between them and the rest of the Israeli

populations. Moreover, the arrangement fuels preexisting tensions between

and within the communities, as not all families receive similar quantities of



water; and families that have obtained a water connection have an interest in

selling water at higher price to others (60).

The MOH is responsible for monitoring water quality. However, the MOH,

too, accepts responsibility only for water quality at the central water points. It

refuses to make any statements regarding water allocation, thus distancing

itself from the political undercurrent. In this case, this means that the MOH

remains passive in a situation in which a population group is denied sufficient

and adequate water supply. It does not initiate or conduct any research on

health matters related to the villagers’ water shortage. Furthermore, the MOH

does not make any efforts to find and promote solutions that reflect principles

of public health ethics or human rights.

The MOH's last water quality survey in the UBVs stems from 1995. It

concluded that both pipeline and well water expose the consumers to severe

health risks, among them mainly bacterial infections (65). Excess morbidity

rates in the Bedouin population are well-documented, especially of infectious

diarrheal and respiratory diseases among children (66-68). However, there are

no comprehensive epidemiological studies that link health problems among

the UBVs' residents to the question of their access to water or environmental

conditions.

The combination of structural discrimination against the Bedouin communities

– which reflects the unequal structure of citizenship in Israel (69, 70) - and the

privatization of a public good creates a tiered model of unequal access to

water which, in turn, translates into unequal health status. A republican



egalitarian approach to bioethics as introduced in the previous section allows

us to consider this case as a clear violation of the right to health and as

unethical. The current water policy vis-à-vis the UBVs not only violates the

right to health of the villagers in that it denies them access to water in

adequate quantity and quality to ensure their health, thus violating their claim

to the amount of goods and services required to guarantee a level of health

equal to that of any other person in Israeli society. The current policy also

breaches the republican formulation of the principles of bioethics in that it

disrespects the tenets of self-government understood as the possibility of

political participation and autonomy. It wrongs the principle of beneficence,

since the notion of the common good is established in and through the

exclusion of the Bedouin communities from decision-making. Discrimination

in the access to water is obviously against the principle of social justice.

Finally, excluding the Bedouin population in the unrecognized villages from

access to water and claiming rights only for the dominant social group violates

the principle of solidarity.

Conclusion

The case of water policies in the UBVs exemplifies the critical possibilities

opened up by a radical egalitarian understanding of the right to health and a

republican conceptualization of bioethics. Firstly, these conceptualizations

expand the scope of bioethics to include those cases that deal not with the

individual but with communities and populations. Secondly, they require



bioethics to address structural inequalities and in this manner serve as a basis

for a genuine public health ethics. Thirdly, a republican bioethics framework

underscores the centrality of equal political participation, its interdependency

with the right to health, and the need for substantial equality in order to realize

both the right to health and the principles of bioethics. Finally, it thus provides

public health professionals with the tools to analyze, criticize and act upon the

inequitable distribution of power and resources as a violation of the right to

health.



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