What Peter Singer Got Wrong (And Where Give Well Could Improve)

The Failure

What Peter Singer got wrong, was he failed to imagine a world which does not need philanthropy. His landmark essay, Famine, Affluence, and Morality does not go far enough in imagining what the affluent ought to do for the impoverished and marginalized people of the world. He makes a compelling moral argument for charitable giving, but I contend the morally superior effort is in aiming to progress the human condition to a place where poverty and marginalization do not exist, where basic rights and freedoms are respected. I will argue it can only begin to happen with equity, not charity.

Regarding Give Well’s Change Our Mind Contest, I am not sure whether this post qualifies, because the goal of the contest is to red team the cost effectiveness of each charity, meanwhile I aim to argue cost effectiveness might not be the most altruistic goal. While I personally value and donate to Give Well’s top charities, every single one of them is a band-aid solution to health problems. Instead of malaria medication and bed nets, we should be seeking the global public good of herd immunity through a vaccine for malaria (I acknowledge this is underway elsewhere); instead of vitamin A supplementation, people deserve an adequate diet which provides sufficient vitamin A; instead of cash transfers for childhood vaccines, we should be supporting implementation of universal health care; instead of deworming, we should seek to understand and prevent the underlying causes of worm infestation.

What if Peter Singer’s drowning child thought experiment reimagined the child in the story to have a sibling who warns him of danger, or a fence preventing his access to the pond? Improving social norms in equity could be that sibling, and preventive health care, social, and economic policies could be the fence. Endorsing a human rights approach to improving health and wellbeing advances these goals. And Peter’s suit would stay clean and dry.

Aiming to Extend Altruism Where Charity Falls Short - The Veil of Ignorance

The state of the human condition is unquestionably better now than it has ever been, but why stop? I have seen EAs indicate that child labour, inequities in vaccine and medication distribution, and growing disparities in income are unfortunate necessities of progress. Why must they be? Why can progress not happen while safeguarding the wellbeing of the least among us?

The heuristic shift is in considering others as agents, rather than patients of our altruistic efforts (to be clear, this post relates to global health and wellbeing causes for humans; meanwhile, non-human animals, the environment, and future people remain patients, deserving of charity. As much as I understand AI, I presume the current situation is to consider AI as patient, but that AI might be agentic one day).

John Rawls “veil of ignorance” is a moral approach to reducing inequity and improving agency. Rawls’ thought experiment requires people to choose their justice principles under a veil of ignorance, meaning they would know nothing about their positions in society. Under the veil of ignorance people would not know their own age, sex, race, social class, religion, abilities, preferences, life goals, or anything else about themselves. They would also be ignorant of the society from which they came. They would, however, have general knowledge about how such institutions as economic systems and governments worked. Rawls argued that only under a veil of ignorance could human beings reach a fair and impartial agreement (contract) as true unbiased equals. They would need to rely on reason to choose principles of social justice for their society. Under such veil, how would you choose a health care system if you might be an Afghan woman, or an HIV orphan in sub-Saharan Africa?

Rawls argued that two principles would emerge from the fair agreement of people behind the veil of ignorance:

1. His First Principle argues that each person has an equal claim to a fully adequate scheme of equal basic liberties, which scheme is compatible with the same scheme of liberties for all.

2. The Second Principle argues that social and economic inequalities are to satisfy two conditions:
a. first, they are to be attached to offices and positions open to all under conditions of fair equality of opportunity; 
b. and second, they are to be to the greatest benefit of the least-advantaged members of society (the Difference Principle).

Incidentally, while John Rawls was a critic of utilitarianism, a common moral framework in EA, research has found that his veil of ignorance in fact supports utilitarian decision-making, including in decisions about donating to the most effective charity.  

Equity vs Efficiency

Yes, promoting equity is where economic efficiency – a key goal of Give Well - and morality intersect. Give Well identifies cost-effectiveness as “the single most important input in our decisions about what programs to recommend”. There are many examples, however, of where efficiency fails to reduce inequality or even improve health. Dr. Paul Farmer highlighted the problem with efficiency in medicine in Pathologies of Power, noting, “the commodification of medicine invariably punishes the vulnerable”, while providing multiple examples in his book. Basically, using market strategies and efficiency to govern health care leaves behind those who have no money to pay for it. Moreover, commodifying medicine reduces patients to a patient, “the diabetic”, rather than a person with agency, who has a job and a family. The veil of ignorance goal would be to pursue an economic arrangement which provides a social system for health care – to the greatest benefit of the least advantaged members of society, per Rawls’ Difference Principle.

Within global health policy, approaches such as malaria bed nets, deworming and vaccine programs are considered vertical health programs, specifically targeting one disease, or a narrow health program, whereas a horizontal health program aims to provide universal basic health care. Most of the arguments against horizontal programs have been lack of efficiency, as opposed to lack of fairness or equity. In 1978 the Alma Ata Declaration of the World Health Organization aimed to implement horizontal health programs and primary health care, but failed to implement due to opposition and lack of funding. 

While universal health care might not be the most efficient system, I would suggest that because EA/Give Well has become quite successful at fundraising, the increase in available funds could mitigate the inefficiencies of supporting universal health care systems.

Which Economic System Improves Equity?

I recently saw a conversation on Twitter between EAs on the economic/social divide between capitalism vs socialism, arguing which endorses greater altruism. The capitalist argued that state-owned means of production does not naturally confer altruism, and an example of this failure of collectivism was the “group project”. The argument for socialism was that capitalism provides no inherent protection of the rights and wellbeing of the oppressed and impoverished. I like these conversations, because they seem to be working toward the same goal of figuring out how to improve the lot of everyone, particularly by considering beneficiaries as agents. I would suggest, however, that market strategies cannot be equitably used for provision of health care, and other social services like education, no matter how well they work for commodities. Amartya Sen, in Development as Freedom, highlights the shortcomings of markets and growth on liberties and freedoms (both essential for people to be agents, rather than patients), using the capabilities approach, “Growth of GNP or of industrial incomes can, of course, be very important as means to expanding the freedoms enjoyed by the members of the society, but freedoms depend on other determinants such as social and economic arrangements, for example, facilities for education and health care, as well as political and civil rights, for example, the liberty to participate in public discussion and scrutiny”. He argues that using mortality as an indicator of economic success and failure, “reminds us of the need to move beyond the cold and often inarticulate statistics …. to look at the various ways in which agency, the capabilities of each person, is constrained”.

Michael Plant, of the Happier Lives Institute, also questions whether growth is the best avenue to improving the human lot in this post. Citing Richard Easterlin, he seeks alternative possibilities to improve collective wellbeing, “More concretely, in his 2021 book, An Economist’s Lessons on Happiness, Easterlin suggests that job security, a comprehensive welfare state, getting citizens to be healthy, and encouraging long-term relationships would increase average wellbeing. All of those seem fairly plausible to me.” Health is inextricably tied to wellbeing and longevity, and I would suggest that envisioning persons as agents by improving equity and social health systems using the veil of ignorance is arguably the most moral approach to improvements in health.

The United State of America provides a stark example of how the market system fails in the area of health care, and how the lack of universal health care impacts health and life expectancy; despite spending far more on health than any other country in the world, the life expectancy of the American population is shorter than in other rich countries that provide varying levels of social health care, but spend far less.

To Summarize

I am suggesting the EA community/Give Well must consider being leaders in the effort of setting new global norms of equity and health as a human right. I am arguing that EA/Give Well move from a cost-effective, vertically-designed charity system for global health, to applying the veil of ignorance to the provision health care. Not the least reason because there is increasing criticism of billionaire philanthropy, suggesting it to be a means of maintaining the status quo of the wealthy and powerful to continue to make decisions for the masses, a position which directly opposes Rawls’ veil of ignorance, and the understanding of persons as agents. Two recent books, Winners Take All, by Anand Giridharadas, and The Globalization Paradox, by Dani Rodrik, have raised this concern.

Action Points

Would Give Well consider causes supporting improved equity and social health care? 
• By promoting horizontal health care strategies which provide universal basic health care
• Through understanding the person as agent, by endorsing health as a human right. In Pathologies of Power Dr. Paul Farmer argues, “human rights are respected when everyone has food, shelter, education, and health care”. The movement to access medication for HIV/AIDS has been instrumental in promoting health as a human right for people living with HIV. 
• A human rights-based approach to improvement of health care might include lobbying the US to ratify the UN Convention on the Rights of the Child. 
• Working with UN Special Rapporteur for Human Rights in Health, Dr. Tlaleng Mofokeng, to determine the wants and needs of people as agents. 
• Supporting activists like Priti Krishtel, a health justice lawyer, MacArthur Fellow, and founder of Initiatives for Medicine, Access and Knowledge, which advocates to reduce patent protection, and thus costs of medication. 

Notably, Dr. Akhil Bansal's prize-winning new EA cause area, addressing Violence Against Women and Girls is an excellent example of a health-related human rights cause.

One Amendment

As I am about to publish this to the forum, across my Twitter feed I see Peter Singer petitioning for the rights of the women of Iran. I stand corrected in suggesting Peter lacks imagination of a world in which everyone enjoys basic rights and freedoms, and will amend to indicate that it was only his 1971 essay which did not imagine it.

ETA: Investing in health systems is a global common good.