Nothing is more politically important to think about, and act upon, than global poverty relief. Numbers can mask the human faces of poverty, but they do bring out its scale: Today, any day, 30,000 children under the age of five will die from preventable illness and starvation. A further 163 million children who will survive this day are severely undernourished. Some 1.2 billion people will try to subsist on less than one dollar a day, while 2.4 billion will not have access to basic sanitation.

In a democratic society, the social rules are imposed by all upon each. As “recipients” of the rules, we tend to think that they should be designed to engender the best attainable distribution of goods and ills or quality of life. We are inclined to assess social institutions by how they affect their participants. But there is another, oft-neglected perspective which the topic of health equity raises with special clarity: As imposers of the rules, we are inclined to think that harms we inflict through the rules have greater moral weight than like harms we merely fail to prevent or to mitigate. What matters morally is not merely how we affect people, but how we treat them through the rules we impose. While current (consequentialist and Rawlsian) theorizing is dominated by the first perspective and thus supports purely recipient-oriented moral conceptions, an adequate approach to social justice requires a balancing of both. Such balancing results in a relational conception of justice, which distinguishes various ways in which an institutional scheme may causally affect the quality of life of its participants.

This essay argues that the strength of our moral reason to prevent or mitigate particular medical conditions depends not only on what one might call distributional factors, such as how badly off the people affected by these conditions are in absolute and relative terms, how costly prevention or treatment would be, and how much patients would benefit from given treatment. Rather, it depends also on relational factors, that is, on how we are related to the medical conditions they suffer. It then discusses some implications of this view for understanding responsibilities for international health outcomes.

This paper discusses obligations of international distributive justice-specifically, obligations rich countries have to transfer resources to poor countries. It argues that the major seven OECD countries each have an obligation to transfer at least one percent of their GDP to developing countries.

The strategy of the paper is to defend this position without having to resolve the many debates that attend questions of international distributive justice. In this respect, it belongs to the neglected category of nonideal theory. The key to the strategy is to show that a significant amount of good would be accomplished by a one percent transfer, despite the fact that one percent is quite a small amount.

To make this showing, the paper takes health as a fundamental measure of individual well-being and examines the improvement in life expectancy that would likely result from devoting the one percent transfer to the major determinants of health. It adduces data indicating that substantial progress towards raising life expectancy in developing countries to the global average of 64.5 years can be expected from expenditures of $125 per capita, divided between health care, education, and basic nutrition and income support. A one percent transfer from the major seven is enough to cover expenditures on that scale for the poorest fifth of the world's population.

Andrew Kuper begins his critique of my views on poverty by accepting the crux of my moral argument: The interests of all persons ought to count equally, and geographic location and citizenship make no intrinsic difference to the rights and obligations of individuals. Kuper also sets out some key facts about global poverty, for example, that 30,000 children die every day from preventable illness and starvation, while most people in developed nations have plenty of disposable income that they spend on luxuries and items that satisfy mere wants, not basic needs.

The main thrust of my argument was that ad hoc suggestions of charity cannot replace a systematic and theoretically informed approach to poverty relief. Charitable donation sometimes helps—and sometimes harms—but is no general solution to global poverty, and can be positively dangerous when presented as such. We need to consider, and often choose, other routes to helping the poor—including ethical tourism and fair trade in luxury goods. We will not be able to invest in such feasible routes if we give away all our extra income, as Singer recommends. Sticking to donation above all, when a combination of other strategies is necessary, is highly likely to harm the poor.

In the lexicon of rights, the concept of human rights can play a wide variety of roles. Human rights can be defined as substantive natural rights that transcend politics and culture or as the rights that underlie political and cultural differences. They can be defined narrowly as rights that could be asserted against enemies in war or, more broadly, as the aspirational goals to which governments are held accountable by their citizens and the world. Despite their lack of recognition in covenant and positive law through much of the twentieth century, human rights are increasingly asserted on the basis of such recognition. To some, human rights are simply the sine qua non (procedural? biological?) for asserting other rights, whatever these may be. In this paper I do not choose among these uses of the concept of human rights by propounding a single definition; neither do I defend or criticize human rights in general.

The one central point in all my writing on this topic, from “Famine, Affluence and Morality” onward, has been that the failure of people in the rich nations to make any significant sacrifices in order to assist people who are dying from poverty related causes is ethically indefensible. It is not simply the absence of charity, let alone of moral saintliness: It is wrong, and one cannot claim to be a morally decent person unless one is doing far more than the typical comfortably-off person does.

No serious student of victimhood and injustice can fail to appreciate their complicated origins and problematic legacies. For individuals and societies emerging from communal violence, oppression, and atrocity, the quest for moral regeneration–through acknowledgment, understanding, and transformation–is as difficult and perplexing as it is pressing. Challenging moral questions abound in the aftermath of human wrongs that admit no easy answers. Indeed, the ethics and politics of transition have been widely contested in theory and practice, by people who share the same basic moral/political concerns to redeem the suffering of victims and to forge a future that never again repeats the violations of the past.

Much of Catherine Lu's response resonates in tone and substance with my article. Like me, Lu speaks in the language of moral psychology and relies heavily on the later work of that preeminent moral psychologist among liberal theorists, Judith Shklar. She agrees, moreover, with both Shklar and me that victimhood (and the fear it produces) is morally damaging more often than not, and that the recent literature on human rights, which focuses on the relation of victim and perpetrator, tends to let the beneficiaries of systemic injustice off the hook. Lu and I, thus, share much common ground that other respondents might have contested, and I am grateful that her perceptive criticisms focus on points within my argument that I am pleased to elaborate.

This brief response cannot adequately address all of the challenging issues raised by Robert Meister in his reply, so I hope only to clarify our main points of contention that will likely continue beyond this exchange.