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Ethical Challenges In LongTerm Funding For HIV/AIDS The moral imperative for shifting priorities from treatment to prevention. by Dan W. Brock and Daniel Wikler ABSTRACT: The global response to the AIDS pandemic aims for universal access to treatment and for pursuing every possible avenue to prevention. Skeptics, doubting that the huge increases in current funding levels needed for universal treatment will ever happen, would scale back antiretroviral treatment in favor of more cost-effective preventive interventions. Economics, politics, and science figure in this debate. But there is also a question of ethical principle: Is there a moral imperative to emphasize treatment, even if emphasizing prevention would save more lives? The authors examine moral arguments that address this question, and come down on the side of saving the most lives via prevention. [Health Aff (Millwood). 2009;28(6):1666–76]
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h e c a s e f o r ac h i e v i n g u n i v e r s a l ac c e s s to treatment for AIDS rests on both medical and moral claims. At one time, it seemed unlikely that antiretroviral therapy could be managed in resource-poor countries. Four million success stories prove otherwise.1 Now that we know we can save these lives at moderate cost, is it not morally clear that expanding access to treatment ought to remain a central goal, and that those with the means to fund antiretroviral treatment have a moral obligation to do so? In this paper we argue that under plausible epidemiological and economic assumptions, the moral argument for emphasizing treatment over prevention is not convincing. Even granting the moral axioms of its proponents, we contend that the argument for continuing to pursue the goal of universal access to antiretroviral treatment fails on its own terms. That same moral outlook, we believe, provides stronger support for a renewed emphasis on prevention, even if this would slow progress on the goal of universal access to treatment.
AIDS Altruism And The Sorcerer’s Apprentice The AIDS pandemic represents the greatest threat to human health and wellbeing in the current generation’s experience. When it became evident that AIDS Dan Brock (
[email protected]) is the Frances Glessner Lee Professor of Legal Medicine in the Department of Global Health and Social Medicine at Harvard Medical School in Boston. Daniel Wikler is the Mary B. Saltonstall Professor of Ethics and Population Health at the Harvard School of Public Health.
1666 DOI 10.1377/hlthaff.28.6.1666 ©2009 Project HOPE–The People-to-People Health Foundation, Inc.
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posed a mortal danger to everyone and not merely to gay men, fear spread broadly in its wake—soon replaced, among the world’s more fortunate, with relief that the risk was concentrated among other populations. It is a great credit to a few individuals, institutions, and agencies that the matter did not rest there. The developed world was persuaded to remain alert to the disease’s toll even though most of its victims—past, present, and future—lived far away and were mostly poor and powerless. The level of resources deployed to assist those at greatest risk, despite lack of kinship, shared history, religion, or other bonds, is unprecedented in human history. Prevention, along with treatment of opportunistic infection, represented the only feasible channel for this altruism as long as treatment for AIDS required very expensive drugs in tertiary care facilities. The precipitous decline in the cost of first-line antiretroviral drugs rallied health workers, activists, governments, and their constituents to press for universal access to treatment. Progress toward realization of this ambitious goal has been rapid, averting disability and death for four million impoverished people with AIDS.1 If this steep upward curve continues, AIDS will continue its transformation from a certain killer to a chronic but treatable disease. Unless and until a cure arrives, this would be grounds for declaring victory. This noble vision for AIDS funding, however, rests on some debatable assumptions. Treatment with antiretroviral drugs is a lifelong proposition. Current funding levels, already high, must be sustained if those now in treatment are to survive. But we are barely past the halfway mark toward the goal of universal treatment,1 and our failure to use every available means to prevent new infections is adding new cases at a rapid rate. Is it reasonable to assume—or even to hope—that the upward curve of funding for treatment will be sustained? That large, permanent increases in current levels of funding will make universal access achievable? And that funding at that level will be sustained indefinitely? If these budgetary assumptions are not credible, some might wish to minimize the implications for the focus of future AIDS funding. Few visionary programs achieve complete success; nevertheless, they can motivate and focus our altruism. But this response is insufficient if (1) emphasizing prevention would save more lives than emphasizing treatment and (2) the supply of funds is highly unlikely to expand so much that more lives will be saved by emphasizing treatment. In that case, given how far we are from achieving universal access to treatment, continued pursuit of that goal would save fewer lives than we could be saving. Even worse, continuing to press for universal access to treatment forecloses the opportunity to revise policy in light of our considered scientific and moral judgment. It is nearly unthinkable that the world will suspend support for those currently enrolled in antiretroviral treatment. Visions of victory over AIDS now compete with images of Sisyphus and the Sorcerer’s Apprentice. “Donor fatigue” is an ever-present danger, and now the world’s economy is battered as well.
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In debates over the future direction for AIDS funding, the choice between goals is stark. And the choice of goals must, in the end, be defended morally. At first sight, this might seem to favor the pro-treatment view. Those favoring renewed commitment to universal access to treatment understandably point to the huge successes achieved thus far, often in the face of unrelenting skepticism, and to the welcome prospect of saving many more lives of people with AIDS as current programs expand. Their opponents have the unenviable task of demonstrating that reducing the priority given to this goal not only comports with economic and epidemiological realities but also would be morally superior. We believe that this can be achieved, and that doing so does not require a choice between moral theories or frameworks. We begin with a moral claim that all can accept: When resources do not permit all to be saved, it is better to save more lives than fewer, provided that the beneficiaries are chosen fairly—all other things held equal. If prevention would save more lives, it is the better choice from a moral point of view—again, if all other things are held equal. This last phrase, however, points to the source of controversy. Those favoring a commitment to providing universal access to treatment insist that all other things are not equal at all. In particular, they argue, a decision to refuse treatment to AIDS patients who will die as a result is morally indefensible. We identify seven grounds for this claim and examine each in turn. We argue that none succeeds, including several that appeal to different aspects of fairness, even if we accept the moral assumptions on which they are based. We then turn our attention to a different kind of pro-treatment argument, one based on the politics of humanitarian assistance. Although we cannot refute it, we remain skeptical. We conclude that future funding for AIDS-related interventions should emphasize prevention over treatment. We confine our analysis to these moral arguments, and we rely on other scholars, including the authors of other papers in this group, for epidemiological, medical, economic, and other data. Space limitations preclude discussion of a number of closely related issues. These include the opportunity costs of focusing on AIDS (both prevention and research) rather than on health systems generally, and the many dilemmas of resource allocation arising within both the pro-treatment and pro-prevention strategies.
Prevention Versus Treatment And The Equal Worth Of Human Lives Along with most other contributors to debates over the direction of future funding for AIDS, we endorse the principle of the equal worth of human lives. That said, this principle can be construed in very different ways, with very different implications. Thus, one could not hope to settle the debate between treatmentfocused and prevention-focused approaches to AIDS funding simply by invoking this principle. Nevertheless, it is far from empty. In particular, it calls upon us to
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value each person’s life independently of his or her economic or other value to society or to others, and regardless of social position or stigma. These are powerful and not universally accepted moral positions; fortunately, they are accepted by most of those on both sides of the prevention-versus-treatment debate. Our ethical analysis begins with a simple extension of the principle of the equal worth of lives: If every life is of equal value, then all else being equal, saving more lives achieves higher value so long as the beneficiaries are selected fairly.
Although this principle—which we refer to here as the “default principle”—is widely accepted by supporters of both sides of the prevention-versus-treatment debate, not all agree on its implications. The moral argument for emphasizing prevention proceeds from this principle and two further claims that rest on scientific and policy data. ! Limited funds. Even on optimistic assumptions about donors’ willingness and capability to sustain and increase funding for AIDS-related interventions, resources will remain inadequate for many years—and possibly forever. The world will not be able to fund full-scale prevention and high-intensity treatment for all patients who could benefit. In all probability, we will have to choose. ! Potential to save lives. Given a fixed budget for interventions, prevention can save more lives. This is the conclusion of numerous analyses.2, 3 Although prevention may be harder to achieve if completely divorced from treatment, according to these analyses, the programs that enable the most people to live will nevertheless strongly favor prevention. ! Strategies. Those who insist on assigning the highest priority to the goal of universal access to treatment may dispute either or both of these further premises, but here we assume their validity. Even so, advocates for universal treatment can use either or both of two strategies to blunt the default principle’s support for prevention. One is to insist that the number of lives saved is not the only relevant moral consideration and that when the full range of relevant concerns is taken into account, treatment emerges as morally superior. In essence, these arguments offer reasons for believing that failing to offer treatment is morally inexcusable—a moral non-option, even if in the end fewer lives are saved as a result. The other claims that over the long run, treatment will save more lives, because in fact budgets are not fixed and an emphasis on treatment tends to make them grow. We consider seven arguments using the first approach; we then turn to the second.
The Obligation To Treat: Six Arguments Equal worth. “Because every life is of equal worth, we must offer the same level of care to every person in need.” This principle, which self-evidently claims the support of the principle of the equal worth of lives, comes in two forms. One invokes a duty of physicians and other health workers not to discriminate among patients on !
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the basis of nationality, wealth, or other considerations that are, morally speaking, irrelevant to their medical need. Doctors would fail to fulfill this duty if they did not offer all patients the same level of care that patients in the richest countries expect. This version of the argument, in our view, bears more on a physician’s personal code of conduct than on the direction of AIDS funding, and we therefore do not assess it. Similar remarks apply to a variation of the physician-based argument that invokes the ethical principle of non-abandonment of patients. At most, this argument would apply only to patients currently enrolled in treatment; the chief question before us is whether to enroll more patients. The other version simply ascribes a right of equal consideration to every human, regardless of nationality, wealth, or social standing. Again, this echoes the principle of the equal worth of lives. But in our view, it is more plausible as a statement of utopian aspirations than as a guide to current policy. The reason is simply that if we obeyed it, we would soon run out of money. The excellent care received by those whom we had managed to treat would not compensate, morally, for the suffering of those whom we might have helped using the same funds for prevention. ! The rule of rescue. According to this argument, the fact that we can save identified people whose lives are imminently threatened by AIDS creates an obligation to do so that must be honored, even if so doing reduces the number of lives saved overall. Coined by ethicist Albert Jonsen,4 this “rule” refers to the common human disposition to rescue identified persons in imminent peril when we have the means to do so. The rule of rescue is frequently cited in discussing the ethics of lifesaving interventions,5 but not always appropriately. Understood as an empirical fact about human psychology, it is undoubtedly correct. But understood as a normative or ethical principle that should guide public policy, it needs an ethical or normative defense.6 The psychological disposition is the felt imperative to rescue those before us without regard to cost. No resources will be spared to try to rescue trapped miners, for example, even if safety measures that would have prevented the cave-in were deemed too expensive when proposed the previous year. The compassionate response to fellow human beings in danger is an ethically important and valuable human trait. The world would certainly not be better if people typically had no concern for the suffering of others.7 Before we favor treatment on the basis of the rule of rescue, however, we must determine whether the so-called rule is a defensible ethical principle, not just a fact about human psychology. Without such defense, it offers no principled reason to ignore our default principle: that it is better to save more lives if we can. Understood as an observation about human psychology rather than as a normative moral principle, the rule of rescue has at best an indirect bearing on the treatment-versus-prevention issue. Perhaps, given the human propensity to rescue those in immediate peril even while avoiding less costly steps to prevent the perils, emphasizing prevention will not motivate people to help as much. According to this argument, the choice is not whether to emphasize prevention or to emphasize
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treatment. Only the latter will draw substantial public support. The actual choice is a well-funded treatment program versus a poorly funded prevention program. This argument has some plausibility, and we return to it below. But it does not answer the question with which we began. Instead, it changes the topic. Our original question was which direction for AIDS funding has the greater moral justification, prevention or treatment. This response says that this is the wrong question to ask, for the public will not support prevention as much as they will support treatment. It leaves the original question unanswered. ! “Identified” versus “statistical” lives saved, and present versus future lives saved. Understood as an ethical principle rather than a psychological disposition, the rule of rescue seems to give ethical importance to two further distinctions: saving identified versus statistical lives,8, 9 and saving lives in imminent danger now versus saving lives at some time in the more distant future. These are different distinctions, and neither of them strictly mirrors the treatment-versus-prevention difference. Sometimes lives saved by a prevention program are identified—for example, when a program prevents an entire identified group from developing a uniformly fatal condition. And sometimes a prevention program may save lives just as quickly as a treatment program—for example, when a program prevents the development of an immediately fatal condition. So even if the identified-statistical and presentfuture differences are ethically important, they would only usually, but not always, support treatment over prevention. But we believe that neither of these differences is morally important. The principle we endorsed above, of the equal worth of all human lives, conflicts with and undermines any moral significance of these differences. Put most simply, statistical lives saved are just as real as identified lives saved; all have the same equal worth. And the same is true for the difference between lives saved in the present versus at some point in the future; they, too, all have equal moral worth. Treatment will save lives now of acutely ill AIDS patients, whereas prevention will keep people from becoming infected, developing AIDS, and dying—say, ten years from now. Why is it better to save 100 lives now rather than even 120 lives ten years from now? Perhaps it is more certain that we can save the lives now. In ten years a cure may exist, treatment may have become much cheaper, or more resources may become available to treat and save later those who become infected in the absence of the prevention program. This shows that we must compare the expected lives saved by each program, adjusting the benefits of each for whatever uncertainty is present. The future lives saved will often, but not always, be more uncertain than the present lives saved. However, if the prevention program is substantially more effective, the number of expected lives saved may still be greater even after this uncertainty is accounted for. Standard cost-effectiveness analysis seems to provide another reason to give priority to the 100 lives we can save now over the 120 we can save in ten years. A temporal discount rate is ordinarily applied to both costs and benefits—a 3 per-
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cent annual rate is common.10 Applying this rate to the 120 lives in ten years reduces them to 89 lives—fewer than the 100 we can save now. But discounting health benefits is controversial and, in our view, a mistake. If we must invest the same amount of money now in each program, with the only difference being that treatment will save 100 lives now, while prevention will save 120 lives in ten years, everything else equal including the uncertainty, why should we give priority to saving fewer rather than more lives? Temporal discounting does not provide a noncontroversial reason to favor treatment over more cost-effective prevention. We acknowledge that partiality to identified lives makes moral sense in some contexts. We may have a stronger moral reason to save an identified person with whom we have a special relationship and to whom we have special obligations, or whom morality permits us to favor over an unidentified stranger. Even between two identified persons, only one of whom I can save, many would allow that I am at least morally permitted, some would say required, to save my spouse rather than a stranger. Philosophers call this an “agent-relative” permission to favor those with whom we have special relationships.11 An individual physician might have such a relationship, and hence a special obligation, to her patients who need treatment. But agent-relative permissions have limited bearing on choices among policies that donors, agencies, and governments face. The scale of their operations ordinarily precludes such relationships with the programs’ potential beneficiaries. That we seem naturally to favor saving identified lives in the present only describes what humans tend to do, not what we should do. If ethical reflection leads us to conclude that we ought not favor fewer identified lives or present lives over more numerous statistical lives in the future, these human dispositions and propensities should be viewed not as a guide to moral choice but as regrettable limitations on our ability to guide our behavior according to our moral reasoning. We should try to overcome these propensities if we wish to do the right thing, just as we must rein in the “fight-or-flight” response to perceived threats and other “natural” but now dysfunctional traits. ! Priority to the worst-off. The justice of a society is often judged by how it treats its worst-off members. Sometimes this is a concern for equality, but equality can support “leveling down”—making the better-off less well off without improving the condition of the worst-off—and few would support that. An alternative interpretation of this concern for the worst-off is called “prioritarianism”—benefiting people matters more, morally, the worse off those people are.12 This special moral concern for the worst-off would seem to justify treatment of AIDS patients who would likely die soon otherwise. By comparison, people served by prevention programs seem less badly off and would receive smaller benefits from such programs. The treated patients have their lives saved, whereas each person served by a prevention program typically experiences only a small to moderate reduction in risk. But this is a misleading and mistaken comparison, and the argument fails on its own terms. Without the prevention program, some people will become HIV-
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infected, develop AIDS, and become patients in need of treatment to save their lives. They will then be just as badly off as the AIDS patients now in need of treatment. The difference is only when each is most badly off. Apart from uncertainty, however, we should not give priority to saving fewer lives now over more lives later, and so the principle of priority to the worst-off offers no support for treatment over prevention. ! Non-aggregation. The reasoning we just followed in considering priority to the worst-off shows why another moral consideration fails to justify greater priority to treatment over prevention than saving the most lives would warrant. A moral problem for cost-effectiveness analysis as a guide to health resource allocation is that the sum of a great number of small inexpensive benefits can exceed the amount of benefit conferred by a relatively few interventions that have high impact on the benefited individuals.13 Cost-effectiveness analysis looks only at the total benefits that different programs will produce; it ignores how those benefits are distributed among individuals. In this instance, it attaches higher priority to relatively trivial benefits than to interventions that might spare people disability or even premature death. In our view, this is a valid reason not to rely on cost-effectiveness alone as a guide to health resource allocation.14 But does the aggregation issue offer support for treatment over prevention? Consider the relative moral importance of providing treatment to an acutely ill AIDS patient versus offering a larger number of people who have a slight risk of infection with HIV a modest reduction in that risk. As an object of compassion, a person suffering from AIDS now presents a stronger claim than someone with a slight chance of becoming infected. Would it be wrong, therefore, to give higher priority to the prevention program, even if it saved more lives? Once again, the argument fails in its own terms. In a large population, the numbers add up, and without prevention there will be many people suffering from AIDS. Each is just as real as the current patient, and their eventual suffering will be every bit as severe. The differences are that this patient’s suffering will occur in the future, and there will be many more such patients if we fail to prevent than if we fail to treat. The aggregation issue does not offer separate or additional grounds for supporting treatment over prevention. ! Urgency. If support for a treatment-centered approach to AIDS is not supported by the principles of priority to the worst-off or of non-aggregation, perhaps a principle of priority to urgent needs will serve. When medical resources are scarce, it is common to treat the most urgent patients first. The rationale for doing so is clear when the scarcity is temporary, as when a serious accident results in the arrival of many critically injured patients all at once in an emergency room. If we don’t treat the most urgent, they will die or suffer irreversible harm, whereas we can treat the less urgent later; in the end, priority to urgent needs permits us to help more—or even all—of those in need. But this is true only when the scarcity is temporary. If resources for AIDS will remain scarce over the long term, we face persistent rather
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“Humanity can congratulate itself on the level of aid that has been provided but must ask whether to stay the present course.” than transient scarcity. Then giving priority to urgency does not let us treat more patients, but simply determines who lives or dies, and there is no compelling moral reason to give priority to the patient with the most urgent need at one point in time. To see this, consider two patients each in need of a heart transplant. One is expected to die in a week, the other in a month, without the transplant. There is only one heart available. The first patient’s need is more urgent. But why should this determine who gets the scarce heart? Perhaps we should favor the patient who is younger over a patient who is much older. Or perhaps we should favor the patient whose health is likely to be best if selected for transplant. These grounds for assigning priority are based on considerations that are of obvious moral salience. When scarcity is not temporary, urgency is simply a matter of timing and is largely irrelevant from a moral point of view. If resources available for AIDS will be persistently scarce, as we assume for this discussion, urgency also fails to provide an independent ground for attaching special moral importance to treatment, where doing so would result in fewer lives saved. We have thus far considered six arguments that seek to show the moral importance of treating people with AIDS, providing considerations that might outweigh the greater lifesaving potential of a prevention-centered approach. If successful, they would show us that a decision to turn away from expanding access to treatment in favor of a stronger effort to prevent infection would be morally indefensible. None succeed, in our view—not because they offend our personal moral views, but because of flaws in their own logic.
Does Treatment Save More Lives By Expanding Budgets? Before drawing our moral analysis to a close, we turn to a different sort of protreatment argument. We mentioned above that one use of the rule of rescue is potentially plausible. It speaks to the greater public appeal of rescuing people suffering from AIDS than of interventions to avoid infection. Even if prevention saves more lives than treatment does at any moment, emphasizing treatment will generate greater donations, enlarging the pool of available resources. In this view, the relevant choice of future directions for AIDS funding is between prevention using resources available today versus treatment using an expanded pool of resources available in the future, provided that we continue to give priority to treatment. If the prospect of treating people with AIDS continues to motivate the exceptional level of altruism that it has done in the past, this argument could be correct. Our focus has been the claim that morality demands that we treat people dying from AIDS and therefore that future funding must continue to give highest prior-
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ity to universal access to treatment. We agree with the premise, but the conclusion does not follow. If funding will remain insufficient, and if a treatmentcentered approach would save fewer lives than one based on prevention, the moral justification for the latter is stronger.
Conclusion The world’s response to the AIDS pandemic has been tragically inadequate. Wealthy countries possess most of the resources needed to save lives and prevent further infection, but they use them for ends that are of vastly less moral significance. Nevertheless, the world’s response more recently has also been surprising and inspiring. Although AIDS has been called a threat to national security for the United States, clearly the principal motivation for the unprecedented commitment of resources has been humanitarian. These funds have been impressive not only in magnitude but also in their implied commitment. Unlike disaster aid after an earthquake or tsunami, AIDS programs must continue year after year. And to reach their goals, they must expand enormously. Humanity can congratulate itself on the level of aid that has been provided but inevitably must ask whether to stay the present course. In our view, the allocation of funds for providing universal access to first-class treatment for AIDS as well as for vigorous deployment of all effective preventive measures would be a better use of the richest countries’ resources than any number of the ends to which they are now committed. If we could rechannel these expenditures, we would do so without hesitation. But since we cannot, that happy outcome does not itself justify staying firmly committed to universal access to treatment for every person with AIDS who needs it as a priority outranking even preventive measures that might, dollar for dollar, save more lives. Doing so, we argue, relies on a speculative judgment about the effects on potential donors of our choices among interventions. With sufficient evidence that this judgment is correct, we would accept that conclusion. But even this argument relies on, rather than rejects, the goal of saving the most lives possible. Considered on the merits, we believe that the strongest moral imperative directs us to give priority to saving the most lives, constrained by considerations of fairness in deciding whom to protect (appeals to the normative version of the rule of rescue, priority to the worst off, and non-aggregation above all were fairness arguments), even if this means lowering the priority given to the goal of universal access to treatment, to provide maximum protection from HIV infection.
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f s t r e s s i n g t r e at m e n t w i l l n o t au g m e n t resources sufficiently to overcome the greater number of lives that could be saved by favoring prevention over treatment, then we find no convincing moral argument for giving priority to treatment when a lack of resources forces us to choose. To be sure, we have not surveyed the full range of these arguments. We have focused on arguments
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that are based primarily on appeals to moral principle that might overturn the default argument in favor of prevention. We understand why some might find these arguments appealing or even convincing, but we conclude that any who might be persuaded by one or more of these arguments should reconsider them in light of the objections we have offered. The authors are grateful to David Bloom, Daniel Halperin, and John Stover for discussion of these issues. NOTES 1.
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3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
World Health Organization. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. September 2009 progress report. Geneva (Switzerland): WHO; 2009 Sep [cited 2009 Sep 20]. Available from: http://www.who.int/hiv/mediacentre/tuapr2009_ru_en.pdf Canning D. The economics of HIV/AIDS in low-income countries: the case for prevention. Cambridge (MA): Program on the Global Demography of Aging, Harvard School of Public Health; 2006 Apr. Working Paper Series no. 18. Marseille E, Hofmann PB, Kahn JG. HIV prevention before HAART in sub-Saharan Africa. Lancet. 2002; 359(9320):1851–6. Jonsen A. Bentham in a box: technology assessment and health care allocation. Law Med Health Care. 1986;14(3–4):172–4. Hadorn DC. Setting health care priorities in Oregon: cost-effectiveness meets the rule of rescue. JAMA. 1991;265(17):2218–25. McKie J, Richardson J. The rule of rescue. Soc Sci Med. 2003;56(12):2407–19. Glover J. Humanity: a moral history of the twentieth century. New Haven (CT): Yale University Press; 2001. Weale A. Statistical lives and the principle of maximum benefit. J Med Ethics. 1979;5(4):185–95. Hammitt J, Treich N. Statistical vs. identified lives in benefit-cost analysis. J Risk Uncertainty. 2007;35 (1):45–66. Keeler EB, Cretin S. Discounting of life-saving and other non-monetary effects. Management Science. 1983;29(3):300–6. Scheffler S. The rejection of consequentialism. Oxford (UK): Oxford University Press; 1988. Brock DW. Priority to the worst off in health care resource prioritization. In: Battin M, Rhodes R, Silvers A, editors. Medicine and social justice. New York (NY): Oxford University Press; 2002. p. 362–72. Kamm FR. Morality/mortality. Vol. I. Death and whom to save from it. Oxford (UK): Oxford University Press; 1993. Brock DW. Ethical issues in the use of cost-effectiveness analysis in health care resource prioritization. In: Anand S, Peter F, Sen A, editors. Public health, ethics, and equity. Oxford (UK): Oxford University Press; 2004. p. 201–23.
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