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Discourse on the idea of sustainability: with policy implications for health and welfare reform

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Abstract

Sustainability has become a major goal of domestic and international development. This essay analyzes the transitions of normative ideas embedded in the notion of sustainability by reviewing the discourses in the representative reports and literature from different periods. Three sets of ideas are proposed: inter- and intra-generational equity, stability of public systems, and a sense of solidarity, which confirms the scope of community and functions as a precondition for the previous two ideas. This essay uses the case of a health system in a hypothetical country to illustrate that, besides securing financial sustainability, a genuinely sustainable public system must also meet the three normative ideas of sustainability. This essay also finds that these three ideas may create intrinsic tensions within the prevalent policy-making model—democracy. The pursuit of sustainability is not only the responsibility of a democratic government, but also a shared moral obligation of the body politic.

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Notes

  1. This is, in some senses, a strong statement. While major international organizations and collaborative efforts, as the essay will show, have recognized the legitimacy and emergency of the sustainability issue, many question it as well. The differences are due to a variety of social, political, economic factors, which however is not the subject of this essay.

  2. As the author is originated from Taiwan, the development of the concept of sustainability in the country could be briefly noted here. Since Taiwan, internationally recognized as the Republic of China, was expelled from the United Nations and replaced by the People's Republic of China (PRC) in 1971, the country has very limited space in global participation. However, the country has managed to incorporate the concept of sustainability into its national institutions parallel to the global trend. In 1992, the Second Amendment of the Constitution of Taiwan included a new article (Article 10) stating that “environmental and ecological protection shall be given equal consideration with economic and technological development”(MOJ 1992/2005). In 1994, the executive branch of the Taiwanese government commissioned the Task Force on Global Transition, which was later promoted as part of the formal administrative institution, the National Council for Sustainable Development, as mandated by the Basic Environment Act of 2002 (Article 9) (MOJ 2002). The definition of sustainable development adopted by the Basic Environment Act is “satisfying contemporary needs without sacrificing the ability of future generations to satisfy their needs” (Article 2) (MOJ 2002), which is identical to that found in the Our Common Future report.

  3. These essential human needs, however, are still unbounded needs, for they include almost every aspect of human activities and are too broad to be operationalized. This unbounded needs problem will be further addressed later.

  4. We could even put aside the “equality of what” question for now.

  5. This intentional vagueness is a common strategy in international collaborations.

  6. The issue of the time scales of sustainability is beyond the scope of this essay. Please refer to Handoh and Hidaka’s work for more discussion (Handoh and Hidaka 2010).

  7. This collectivist notion of solidarity is different from the aggregation of minds of individuals. Individuals might form minds that correlate one with another in different aspects through direct interpersonal connections, and these individualist sentiments are sometimes also referred as solidarity. Collectivist solidarity might be related to these individualist sentiments, but is a sentiment at the population level. It could be, but not necessarily, derived from direct interpersonal connections. In many cases, it is derived from connections between members of a “imagined” collectivity, or, a community (Anderson 2016).

  8. Consider what political philosopher John Rawls has well argued. A stable just institution will require people to have a sense of justice to sustain (p. 453–458) (Rawls 1971). These people see each other as free and equal moral agents. They make collective political decisions and social cooperation to maintain the public institution according to the conception of justice (p. 472–476). Their sense of justice attached to the public institution is derived not from self-interests or other emotions, but from their recognition of the conception of justice. However, Rawls’s argument is based on the presumption that people are already situated in a well-ordered society with just institutions (p. 453–458), while we are clearly situated in a society that is far from well-ordered, let alone the conception of justice people believe in. Under these circumstance, solidarity might be an alternative to sense of justice as the psychological grounds to sustain the stability of public systems.

  9. Even for the members of a family is not blood related, their legal relationship is modeled as if they are in a blood family.

  10. For policymakers under different contexts in different countries to steer these sentiments, we are certainly not satisfied with this undefined account of normative solidarity. Country case-based empirical researches are needed to investigate the values of the health systems and the sentiments shared by the peoples.

  11. For instance, scholars have proposed global solidarity and human solidarity as concepts to address solidarity in health sector (Reichlin 2011; West-Oram and Buyx 2017; West-Oram 2018).

  12. Like the ones in Taiwan, South Korea, (Wong 2004), and in the provinces in Canada (Marchildon 2013). The insurer in a national health insurance program is often a single-payer insurer run by the government. Contributions are made by employers, employees, and the government from general tax revenues. For a fuller list of countries adopting national health insurance programs and the discussion of the typology of NHI, please refer to the analysis proposed by Cuadrado and colleagues (Cuadrado et al. 2019). This hypothetical scenario presented here is, in a sense, also applicable to countries with national health service systems, like England (Miller 1995).

  13. “Equitable access to health services” used here is just an example. It is closer to Solow’s definition of sustainability, which emphasizes the future generation’s enjoyment of a standard of living at least as good as our own (Solow 1993). If we were to adopt the definition of the Our Common Future report, the value upheld by the system would be “health needs” that are essential to human life (WCED 1987). If we were to adopt Sen’s definition, it would be “health services related to the building of capabilities” to enable people to enjoy substantive freedoms (Sen 2009). Of course, these are very simplified notions of values for the simplicity of discussion. In real-world cases, health systems are built for different purposes in different contexts, which would be worth investigating but is beyond the inquiry of this essay.

  14. As Stone has rightly put, policy-making is all about the struggle of ideas (Stone 2002).

  15. If we are not proponents of democracy, it may be much easier to convey the idea of sustainability. For instance, if we are policy elites believing in the concept of sustainability but do not believe in democracy, we may easily adopt a top-down approach that pushes the three sets of ideas of sustainability, regardless of the general public’s will.

References

  • Anderson, Benedict. 2016. Imagined Communities: Reflections on the Origin and Spread of Nationalism. London: Verso.

    Google Scholar 

  • Chiang, Tung-Liang. 1997. Taiwan's 1995 Health Care Reform. Health Policy 39 (3): 225–239. https://doi.org/10.1016/S0168-8510(96)00877-9.

    Article  Google Scholar 

  • Cuadrado, Cristóbal, Francisca Crispi, Matías Libuy, Gregory Marchildon, and Camilo Cid. 2019. National Health Insurance: A Conceptual Framework from Conflicting Typologies. Health Policy 123 (7): 621–629. https://doi.org/10.1016/j.healthpol.2019.05.013.

    Article  Google Scholar 

  • Daniels, Norman. 1983. Justice Between Age Groups: Am I My Parents' Keeper? The Milbank Memorial Fund Quarterly. Health and Society 61(3):489–522.

    Article  Google Scholar 

  • Dawson, Angus, and Marcel Verweij. 2012. Solidarity: A Moral Concept in Need of Clarification. Public Health Ethics 5 (1): 1–5.

    Article  Google Scholar 

  • Delkeskamp-Hayes, Corinna. 2015. Morality at the Expense of Others: Equality, Solidarity, Taxes, and Debts in European Public Health Care. Journal of Medicine and Philosophy 40 (2): 121–136. https://doi.org/10.1093/jmp/jhu075.

    Article  Google Scholar 

  • Gusmano, Michael K., and Kieke G.H. Okma. 2018. Population Aging and the Sustainability of the Welfare State. Hastings Center Report 48 (S3): S57–S61. https://doi.org/10.1002/hast.915.

    Article  Google Scholar 

  • Handoh, Itsuki C., and Toshitaka Hidaka. 2010. On the Timescales of Sustainability and Futurability. Futures 42 (7): 743–748. https://doi.org/10.1016/j.futures.2010.04.023.

    Article  Google Scholar 

  • Harlow, John, Aaron Golub, and Braden Allenby. 2013. A Review of Utopian Themes in Sustainable Development Discourse. Sustainable Development 21 (4): 270–280. https://doi.org/10.1002/sd.522.

    Article  Google Scholar 

  • Houtepen, Rob, and Ruud ter Meulen. 2000. New Types of Solidarity in the European Welfare State. Health Care Analysis 8 (4): 329–340.

    Article  Google Scholar 

  • Kemp, René, Saeed Parto, and Robert B. Gibson. 2005. Governance for Sustainable Development: Moving from Theory to Practice. International Journal of Sustainable Development 8 (1–2): 12–30.

    Article  Google Scholar 

  • Krishnamurthy, Meena. 2013. Political Solidarity, Justice and Public Health. Public Health Ethics 6 (2): 129–141. https://doi.org/10.1093/phe/pht017.

    Article  Google Scholar 

  • Lamuran, Syaman, Shih-Hui Hsiao, and Huei-Ming Tsai. 2015. Tao People's Response to Modern Environmental Governance and the Development of the Sustainable Environmental Governance (In Taiwanese Traditional Chinese). Journal of the Taiwan Indigenous Studies Association 5 (3): 1–44.

    Google Scholar 

  • Liaropoulos, Lycourgos, and Ilias Goranitis. 2015. Health Care Financing and the Sustainability of Health Systems. International Journal for Equity in Health 14 (1): 80. https://doi.org/10.1186/s12939-015-0208-5.

    Article  Google Scholar 

  • Maarse, Hans, and Aggie Paulus. 2003. Has Solidarity Survived? A Comparative Analysis of the Effect of Social Health Insurance Reform in Four European Countries. Journal of Health Politics, Policy and Law 28 (4): 585–614.

    Article  Google Scholar 

  • Marchildon, Gregory P. 2013. Canada: Health System Review. Health systems in transition 15 (1): 1–179.

    Google Scholar 

  • Meadowcroft, James. 2007. Who is in Charge Here? Governance for Sustainable Development in a Complex World. Journal of Environmental Policy & Planning 9 (3–4): 299–314.

    Article  Google Scholar 

  • Meadows, Donella H., Dennis L. Meadows, Jørgen Randers, William W. Behrens, and III. 1972. The Limits to Growth. New York: Universe Books.

    Google Scholar 

  • Miller, David. 1995. On Nationality. Oxford : Oxford Clarendon Press.

    Google Scholar 

  • MOJ. 1992/2005. Additional Articles of the Constitution of the Republic of China. https://law.moj.gov.tw/ENG/LawClass/LawAll.aspx?pcode=A0000002. Accessed 2 April 2019.

  • MOJ. 2002. Basic Environment Act https://law.moj.gov.tw/ENG/LawClass/LawAll.aspx?pcode=O0100001. Accessed 2 April 2019.

  • Moyer, Jonathan D., and David K. Bohl. 2019. Alternative Pathways to Human Development: Assessing Trade-offs and Synergies in Achieving the Sustainable Development Goals. Futures 105: 199–210. https://doi.org/10.1016/j.futures.2018.10.007.

    Article  Google Scholar 

  • Nussbaum, Martha C. 2007. Frontiers of Justice: Disability, Nationality, Species Membership. Cambridge, MA: Harvard University Press.

    Google Scholar 

  • van Parijs, Philippe. 1998. The Disfranchisement of the Elderly, and Other Attempts to Secure Intergenerational Justice. Philosophy and Public Affairs 27 (4): 292–333.

    Article  Google Scholar 

  • Prainsack, Barbara, and Alena Buyx. 2017. Solidarity in Biomedicine and Beyond. Cambridge: Cambridge University Press.

    Book  Google Scholar 

  • Rawls, John. 1971. A Theory of Justice. Cmabridge, MA: Harvard University Press.

    Google Scholar 

  • Redden, Candace Johnson. 2002. Health Care as Citizenship Development: Examining Social Rights and Entitlement. Canadian Journal of Political Science/Revue canadienne de science politique 35 (01): 103–125.

    Article  Google Scholar 

  • Reichlin, Massimo. 2011. The Role of Solidarity in Social Responsibility for Health. Medicine, Health Care and Philosophy 14 (4): 365–370. https://doi.org/10.1007/s11019-011-9320-5.

    Article  Google Scholar 

  • Sachs, Jeffrey D. 2012. From Millennium Development Goals to Sustainable Development Goals. The Lancet 379 (9832): 2206–2211.

    Article  Google Scholar 

  • Sachs, Jeffrey D. 2015. The Age of Sustainable Development. New York: Columbia University Press.

    Book  Google Scholar 

  • Sahlins, Marshall. 1972. Stone Age Economics. Chicago: Aldine-Atherton.

    Google Scholar 

  • Saltman, Richard B., and Hans F. W. Dubois. 2004. The Historical and Social Base of Social Health Insurance Systems. In Social Health Insurance Systems in Western Europe, eds. Richard B Saltman, Reinhard Busse, and Josep Figueras, 21–32. European Observatory on Health Care Systems Series. London: Open University Press/McGraw-Hill Education.

    Google Scholar 

  • Sangiovanni, Andrea. 2015. Solidarity as Joint Action. Journal of Applied Philosophy 32 (4): 340–359.

    Article  Google Scholar 

  • Sen, Amartya. 2009. The Idea of Justice. Cambridge, MA: Harvard University Press.

    Book  Google Scholar 

  • Solow, Robert M. 1991. Sustainability: An Economist's Perspective. Seward Johnson Lecture to the Marine Policy Venter, Woods Hole, MA: Paper presented at the The Eighteenth J.

    Google Scholar 

  • Solow, Robert M. 1993. An Almost Practical Step Toward Sustainability. Resources Policy 19 (3): 162–172. https://doi.org/10.1016/0301-4207(93)90001-4.

    Article  Google Scholar 

  • Stone, Deborah. 2002. Policy Paradox: The Art of Political Decision Making, Revised ed. London and New York, NY: WW Norton and Company.

    Google Scholar 

  • Tremmel, Joerg Chet. 2006. Establishing intergenerational justice in national constitutions. In Handbook of Intergenerational Justice, ed. Joerg Chet Tremmel, 187–214. Cheltenham: Edward Elgar.

    Chapter  Google Scholar 

  • Tseng, Yu-Hwei, and Tung-Liang Chiang. 2017. Towards a new era of development: from MDGs to SDGs (In Taiwanese Traditional Chinese). Taiwan Journal of Public Health 36 (1): 1–5.

    Google Scholar 

  • UN. 1972. Declaration of the United Nations Conference on the Human Environment. Stockholm: United Nations.

  • UN. 2015a. Resolution adopted by the General Assembly on 25 September 2015: Transforming our world: the 2030 Agenda for Sustainable Development. https://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E. Accessed 2 April 2019.

  • UN. 2015b. Sustainable Development Goals. https://www.un.org/sustainabledevelopment/sustainable-development-goals/. Accessed April 2 2019.

  • UNCED. 1992. Rio Declaration on Environment and Development. The United Nations Conference on Environment and Development.

  • van Egmond, N.D., and H.J.M. de Vries. 2011. Sustainability: The Search for the Integral Worldview. Futures 43 (8): 853–867. https://doi.org/10.1016/j.futures.2011.05.027.

    Article  Google Scholar 

  • WCED. 1987. Report of the World Commission on Environment and Development: Our Common Future. United Nations: World Commission on Environment and Development.

    Google Scholar 

  • Weiss, Edith Brown. 1990. Our Rights and Obligations to Future Generations for the Environment. American Journal of International Law 84 (1): 198–207.

    Article  Google Scholar 

  • West-Oram, Peter. 2018. Solidarity as a National Health Care Strategy. Bioethics 1: 11. https://doi.org/10.1111/bioe.12443.

    Article  Google Scholar 

  • West-Oram, Peter G.N., and Alena Buyx. 2017. Global Health Solidarity. Public Health Ethics 10 (2): 212–224. https://doi.org/10.1093/phe/phw021.

    Article  Google Scholar 

  • WHA. 2005. WHA58.33 - Sustainable Health Financing, Universal Coverage and Social Health Insurance. https://apps.who.int/medicinedocs/en/m/abstract/Js21475en/. Accessed April 2 2019.

  • Wong, Joseph. 2004. Healthy Democracies: Welfare Politics in Taiwan and South Korea. Ithaca, NY: Cornell University Press.

    Google Scholar 

  • Yeh, Ming-Jui. 2019. Exploring Users’ Perceptions and Senses of Solidarity in Taiwan’s National Health Insurance. Public Health Ethics 12 (1): 1–14. https://doi.org/10.1093/phe/phy021.

    Article  Google Scholar 

Download references

Acknowledgements

The author thanks Po-Han Lee, Tzu-An Chiu, David Mai and Wei-Hsiang Liao for their comments. An earlier draft of this paper was presented at the 2017 Taiwan Public Health Association Annual Conference, Kaohsiung Medical University, October 28–29.

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Yeh, MJ. Discourse on the idea of sustainability: with policy implications for health and welfare reform. Med Health Care and Philos 23, 155–163 (2020). https://doi.org/10.1007/s11019-019-09937-z

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