It is difficult to think of a timelier book than Nicole Hassoun’s Global Health Impact: Extending Access to Essential Medicines. The book was written before COVID-19 hit societies around the world (except for the preface, which does mention the pandemic). ^{Footnote 1} However, it addresses an issue that current efforts to roll out vaccines have placed on the top of news headlines and political agendas globally: access to medicines. Hassoun reminds us that a lack of access to essential medicines is nothing new, but a persistent problem in low-income countries, where life-saving drugs for diseases such as malaria, tuberculosis (TB) and HIV/AIDS remain unavailable to millions of people. She forcefully argues that this situation is a serious moral failure and proposes realistic remedies.

Global Health Impact is based on Hassoun’s broad and extensive scholarship on topics such as global justice, human rights, empirical philosophy and corporate responsibility, and her work as director of the Global Health Impact project (https://www.global-health-impact.org/new), a collaboration between academics and civil society organizations aimed at increasing access to essential medicines. It is thus a multifaceted book of potential relevance to a diverse readership, including moral and political philosophers, health economists, global health experts, health policymakers and human rights activists. It stands out from most other philosophical work in this area by its deep engagement with other disciplines, its sophisticated practical proposals, and its emphasis on consumer responsibility. These features bring important qualities to the book but, as noted below, also raise some difficult questions.

Global Health Impact consists of three parts. The first part defends the idea of a human right to health and explores some of its key implications. Chapter 1 argues that everyone should have an enforceable legal human right to a basic minimum of health, including a right to access essential medicines, because this right protects people’s ability to live minimally good lives. To live such a life, Hassoun argues, one needs ‘(1) an adequate range of (2) the fundamental conditions (3) necessary and/or important for (4) securing those (5) relationships, pleasures, knowledge, appreciation, and worthwhile activities, etc. that (6) a reasonable and caring person would set as a minimal standard of justifiable aspiration’ (19, emphasis in original). One’s prospects for such a life will be poor unless one enjoys minimal health, including access to needed drugs, Hassoun argues. She also suggests that this account has several advantages over other ways of grounding the right to health or human rights in general, including those appealing to capabilities, normative agency and equality of opportunity.

Chapter 2 argues that the human right to health should give rise to the virtue of ‘creative resolve’, which ‘strongly disposes people to think creatively about how to overcome obstacles to fulfilling significant moral requirements and to attempt to fulfill them where possible and permissible’ (39). As this quote suggests, creative resolve rests on an instrumental rationale: it encourages bearers of duties correlative to the right to health, and beneficiaries and human rights advocates, to not just recognize this right but also work hard to ensure its fulfilment. Hassoun illustrates her argument by showing how actors committed to the right to health have exercised something like this virtue in practice. She also responds to those who question the right to health on the grounds that it does not help decision-makers ration scarce resources, arguing that this is not its most important role. While rationing (understood as limiting access to goods necessary for a minimally good life) is sometimes unavoidable, we should not take claims about its necessity at face value. Decision-makers must exercise creative resolve in attempting to avoid rationing (thus ensuring that everyone’s needs are met), for instance by using resources more efficiently, before resorting to it.

The second part of the book details the Global Health Impact project’s activities and examines the responsibilities of different actors to support these. Chapter 3 presents the Global Health Impact model, which is a system for evaluating the global health impact of key drugs. The evaluation uses data on the need for these drugs (the disability-adjusted life years (DALYs) lost to diseases they treat), access to them (the percentage of those who need the drugs that receive treatment), and their effectiveness or efficacy. Based on this evaluation, the Global Health Impact index rates pharmaceutical companies in terms of the aggregate impact of their products. This creates various possibilities for incentivizing industry to address the access to medicines problem, through inventing new drugs or improving access to existing drugs. The most developed proposal is to give highly rated companies a label that they can attach to all their products – from prescription medicines to vitamins, sunscreen, and baby oil – to attract consumers. Hassoun estimates that if a company can increase its market share for consumer healthcare products by 1% in this way, this represents a US$2 billion incentive to do so, more than the estimated yearly R&D cost for a new drug. Other possibilities include using the rating for socially responsible investment and universities’ agreements to license inventions to pharmaceutical companies. Hassoun notes that the proposed initiatives have already had some uptake within, amongst others, the United Nations, the World Health Organization, and certain pharmaceutical companies.

Chapter 4 argues that individual consumers should buy products from Global Health Impact-certified companies. The argument appeals to two moral shortcomings of the pharmaceutical industry. First, while Hassoun does not reject the global patent system as such, she contends that drug companies exploit this system in ways that violate people’s right to access to essential medicines, e.g. by aggressively extending and multiplying patent protections that keep drugs unaffordable in poor countries and by lobbying against compulsory licensing. Second, she argues that since drug companies contribute to, benefit from and are especially well-placed to address the access to medicines problem, they have a special obligation to address it, an obligation they currently fail to fulfil. Insofar as buying certified goods can be expected to encourage industry to overcome these shortcomings (as Chapters 3 and 6 argue) individuals should buy these goods.

The book’s third part deals with broader questions of consumer responsibility and with assessing the empirical support for Global Health Impact initiatives. Chapter 5 argues that consumption seeking to achieve morally important outcomes (such as improving access to essential medicines) is permissible, possibly even obligatory, even when it does not aim at democratic change and does not operate through democratic procedures. Hassoun thus rebuts the view that consumption must be democratic in some such way in order to be ethical. On her institutional view, individuals are generally free to consume (and otherwise act) as they please as long as they follow the rules set by just institutions. But in our non-ideal world, where institutional rules are neither just nor fully obeyed, there are important moral constraints on consumption, including respect for basic rights and concern for the natural environment. However, these constrains are not democratic. Advancing democracy can be a laudable aim of consumption. But insisting that consumption choices must have this aim, or be in some sense procedurally democratic, blocks valuable opportunities for moral progress.

Chapter 6 provides some empirical evidence in support of the initiatives proposed in the book and discusses how to gather more evidence for these and similar initiatives. This involves a detailed discussion of how to combine philosophy with empirical science. While so-called experimental philosophy often uses surveys to study the intuitions of ordinary people about philosophical problems, Hassoun proposes that philosophers employ other empirical methods too (or collaborate with scientists trained in these methods). She notes that philosophical arguments about practical matters often involve empirical premises that must be substantiated to establish the conclusions unconditionally. For instance, establishing that consumers should purchase Global Health Impact-labelled goods requires providing evidence that this can be expected to incentivize industry to improve access to medicines. Hassoun here provides such evidence in the form of results from an experimental study showing that such labelling affects how consumers perceive the quality of brands and companies. She also details how labels’ effects on real consumption choices can be studied through a field trial. Moreover, the chapter discusses how to collect evidence for other initiatives to improve access to medicines and advance global justice, and why empirical research needs philosophy (and not just the other way around).

Global Health Impact is an impressive book. Hassoun has a remarkable capacity to move across disciplinary boundaries and bring rigorous philosophical argument to bear on pressing real-world problems. It is a delight to see the relevance of philosophy and the potential of interdisciplinary work so forcefully demonstrated. The book should also be commended for its lively style and clear prose, though its accessibility is somewhat limited by the density of certain chapters and the liberal use of discursive footnotes, some of which are not perfectly aligned with the main text.

Such a bold book is bound to stick its neck out. While Hassoun responds to many criticisms, helpfully referring the reader to publications where key issues are discussed in greater detail, questions and possible concerns remain. Some of these pertain to the Global Health Impact model and its proposed uses, others to underlying philosophical issues.

Regarding the model, it is notable that the focus is exclusively on the outcome of drugs (DALYs averted) and that each company is rated based on the aggregate impact of its drugs. These features make significant sense given the aim to incentivize industry to alleviate as much death and disability as possible. However, they also raise the concern that companies receive credit on morally arbitrary grounds. To begin with, larger companies are favoured over smaller ones only because of the size of their market share. Moreover, while the accessibility and impact of drugs may certainly reflect companies’ behaviour, it may to an equal or larger extent reflect the conduct of other actors. For instance, a large healthcare system’s decision to procure or subsidize a drug, or a large humanitarian organization’s use of the drug in its campaigns, may presumably significantly boost its impact, even absent any effort of the company to make the drug available. Rewarding the company for the increased impact in such cases might seem arbitrary. So too might not rewarding companies that invest significantly in expanding access to their drugs when these drugs end up having less impact due to the actions or omissions of other actors or other factors beyond the companies’ control, or simply because their market share is small.

It might be responded that worries about arbitrariness are misplaced in the present context, since what really matters is the model’s capacity to effectively incentivize industry to save lives and alleviate disability. However, such worries may be important (albeit indirectly) even if we only care about effectiveness. The uptake of the model will depend on its legitimacy among pharmaceutical companies, policymakers, and consumers, which in turn is plausibly affected by whether it is seen as distributing rewards on morally relevant grounds. How sensitive these stakeholders are to perceived arbitrariness in the distribution criteria is of course an empirical question. However, above some level, perceived arbitrariness seems likely to limit the model’s legitimacy, hence its uptake, hence its effectiveness.

A further question is whether rating companies based on aggregate impact is suitable for promoting access to medicines in cases where a variety of drugs from different companies is needed. Consider antibiotics. The lack of access to these drugs accounts for a large share of the disease burden in the developing world. However, increased access must be balanced with appropriate use to minimize the development of antibiotic resistance, which undermines the effectiveness of these drugs (Laxminarayan et al. Reference Laxminarayan, Duse and Wattal2013). Striking this balance requires having a variety of different antibiotics available to ensure each patient receives optimal treatment. It is unclear that rewarding the companies with the greatest aggregate impact helps protect or promote such variety. And if not, the question arises how the rating system might be adapted for this task, or perhaps combined with other incentives.

These reflections are certainly not intended as reasons to reject the Global Health Impact model or its proposed uses. However, they illustrate the complexity of the issues that Hassoun deals with and the challenges of fine-tuning incentive mechanisms to achieve desired effects.

Regarding the underlying philosophical issues, Hassoun moves with admirable ease between a number of complex contemporary debates, concerning, amongst others, the grounds of human rights, the distribution of special responsibilities, ideal versus non-ideal theory, and philosophical methodology. This helpfully introduces the reader to these debates and demonstrates their real-world relevance. On the other hand, readers primarily interested in specific philosophical issues might occasionally find the discussion too quick. Again, however, plenty of footnotes and references to earlier work are available for those wishing to dig deeper. Moreover, the compact treatment of the human right to health in Chapter 1 is accompanied by a penetrating discussion (one of the book’s philosophical highlights) in an appendix of the right to health and public goods.

Given the wide range of issues covered, it is fair to ask how the pieces of Hassoun’s theory fit together and how her theoretical arguments support her practical proposals. Like many other human rights theorists, Hassoun thinks of human rights in a sufficientarian way. The right to health helps ensure that everyone is able to reach a threshold: the minimally good life. However, the Global Health Impact model measures the aggregate impact of drugs regardless of whether those treated are above or below such a threshold, and thus seems insensitive to sufficientarian concerns. Perhaps this observation is merely of theoretical interest in the case of malaria, TB and HIV/AIDS, because everyone who lacks access to treatment for these conditions can plausibly be assumed to be below the threshold. (Or perhaps the model is not meant to reflect Hassoun’s theory of human rights; the book’s three parts are described as mutually independent (7).) However, the proposed extension to new conditions (102), some of which are possibly less serious than those targeted so far, may make the contrast between the theory and the model more salient, raising intriguing questions about the feasibility and desirability of building sufficientarian considerations into the model.

Moreover, one might wonder why creative resolve is conceptualized as a virtue rather than simply as a corollary to the obligations corresponding to the right to health. As Hassoun stresses, the idea of an enforceable legal human right to health entails weighty obligations on the part of states and other actors, including pharmaceutical companies and consumers. Being disposed to seek to overcome obstacles to the fulfilment of one’s moral obligations (when possible, morally permissible, and not too costly) is arguably part of what it means to have such obligations in the first place. By contrast, calling this disposition a virtue may suggest that acquiring or exercising it is supererogatory or only mildly obligatory. This does not exclude that virtue talk has its place in this context, of course: some efforts to improve access to medicines (e.g. activism or certain forms of philanthropy) may be morally admirable or inspiring, yet not obligatory. However, for an important range of actors and situations, creative resolve might be better conceived in deontic rather than aretaic terms.

Furthermore, one might endorse the arguments for ethical consumption in Chapter 4, yet think that these arguments warrant different, stronger practical conclusions. If (as Hassoun contends) pharmaceutical companies violate human rights by aggressively extending patents and fail to fulfil weighty obligations to remediate the access to medicines problem they are behaving morally badly indeed. Rewarding companies that perform less badly than their competitors in these respects by purchasing their products might seem too weak a response to such gross moral failures. Stronger consumer responses (maybe selective boycotts) targeting the whole industry or at least the particularly bad apples are plausibly warranted.

Perhaps more importantly, ethical consumption choices, though laudable, should arguably not be the main response to drug companies’ moral failures. Political action seems more fitting. Now Hassoun assumes that states have the primary duty to ensure access to essential medicines, but that states fail to do what they should, giving other actors, including drug companies, secondary duties. However, this does not obviously exclude that states, especially well-resourced ones with above-average human rights performance, should seek to enforce drug companies’ secondary duties, e.g. through reforming the patent system, pursuing compulsory licensing, or perhaps new or increased taxes on the industry, at least when this is more feasible or effective than directly improving their own or other states’ behaviour. Nor does it exclude that individuals should seek to influence governments to enforce drug companies’ duties (in addition to fulfilling governments’ own duties). Such political responses are of course not incompatible with ethical consumption (and a potential practical worry is that promoting them may turn the pharmaceutical industry against Hassoun’s important project). However, they seem to better match the underlying arguments. At least one would want compelling reasons to think that they are unfeasible or unjustified before relying primarily on consumer responsibility.

In a broader perspective these are minor quibbles. Global Health Impact is a brilliant, topical and engaging book, which can be expected to significantly advance scholarly debates about global justice, human rights, access to medicines and interdisciplinarity. One also wishes much success to the practical efforts to advance global health justice that it seeks to inspire.