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Abstract

Cosmopolitanism is an old concept that was used in social and political theories to highlight the commonality among human beings as members of the same universal community. However, it was recently introduced to discuss the issue of health and moral responsibility for its disparities. This entry will start by brieﬂy outlining the historical use of the term and its various connotations with the numerous contexts in which it was used. It will then highlight the central ideal aspired by cosmopolitan advocates. The entry will then focus on discussing the central themes of cosmopolitanism and its relevant objections in regard to global bioethics including responsibility, justice, and disparities in health and healthcare. The discussion will also unfold some of the global determinants of health and current practical approaches to address them.

Introduction

Cosmopolitanism is an old concept that was used in social and political theories to highlight the commonality among human beings as members of the same universal community. However, it was recently introduced to discuss the issue of health and moral responsibility for its disparities. This entry will start by brieﬂy outlining the historical use of the term and its various connotations with the numerous contexts in which it was used. It will then highlight the central ideal aspired by cosmopolitan advocates. The paper will then focus on discussing the central themes of cosmopolitanism and its relevant objections in regard to global bioethics including responsibility, justice, and disparities in health and healthcare. The discussion will also unfold some of the global determinants of health and current practical approaches to address them.

Brief History Of Cosmopolitanism

Cosmopolitanism is an expression derived from Greek kosmopolites (cosmos and polites) that literally means citizens of the world (or universe). The expression was ﬁrst coined by Diogenes the Cynic in the fourth century BC. He proudly expressed his belonging to a universal community of equal human beings that extends beyond the city-state to which he belonged. He, therefore, emphasized that belonging to the human race trumps the parochial belonging to any speciﬁc community.

This idea was taken later on by the Stoics of the third century AD and was integrated into their inclusive philosophical worldview. They believed that the entire world is governed by the logos, i.e., the reason behind everything. Wherefore, recognizing that every human being has rational faculties through which he may have access to the logos, they emphasized the equality of all humans in a uniﬁed community. They recognized, though, that to better serve other human beings, political engagement and institutions are necessary. Their version of cosmopolitanism may have connections to the idea of “natural law,” a moral law believed to be equally ingrained in all human beings regardless of their religious afﬁliation.

Nurtured on these philosophical premises, the Greco-Roman empire thrived around the Mediterranean and extended in all directions to include numerous communities with many cultural makeups. Within this centralized but inclusive political environment, the city-states came into active interaction and exchange among themselves. Moreover, Christianity, which ﬂourished within this inclusive political system, integrated the idea of cosmopolitanism into its theological system under various understandings, including “Catholicity” (cath, every; olon, thing/body) and “universality” (i.e., its universal salviﬁc mission) and “ecumenism” (oecomeni, inhabited land, before it became to mean intra-Christian dialogue).

The understanding of cosmopolitanism in Western Christianity took a different path than that in Eastern Christianity. Under the inﬂuence of the Augustinian theology, there was a differentiation in the West between the citizens of the city of God and those who do not belong to that city. This differentiation led in political philosophy to the contrast between temporal political authority and universal church authority. Such contrast continues to this day in the dichotomy between the secular and the religious and in the political separation between church and state in Western countries. Eastern Christianity did not develop this dichotomy and experienced different dynamics in shaping the political systems in countries where its believers constitute a majority.

The aspirations of the cosmopolitan ideal were revived at the dawn of the Enlightenment and the exploration of the Hellenistic tradition by its heralds. Both the American and French revolutions harbingered the cosmopolitan ideal in modern times through their emphasis on the equality of all rational human beings, although the application lagged behind the theory. Within that historical context, Immanuel Kant (1724–1804) shaped the philosophical ideal of cosmopolitanism especially in his book Perpetual Peace (1795) and theorized on a pragmatic world order to achieve that ideal. His aspiration to establish a peaceful coexistence of different nations still resonates to this current day. While the American and French revolutions were seminal in nourishing the human rights ideals at the personal level, Kant’s project was central to shaping the League of Nations and the United Nations as political organizations between the two world wars and since the end of the second, respectively. Many historical events catalyzed the adoption of cosmopolitanism at various levels, such as through moving toward economic globalization and through the institution of several international nongovernmental organizations (e.g., Red Cross and Red Crescent societies and Doctors Without Borders). Most recently, the ideal of belonging to one global human community played a major role in shaping some international documents with a special emphasis on global health such as the UNESCO Universal Declaration on Bioethics and Human Rights.

In A Nutshell Cosmopolitanism

In a thorough study of the historical development of the ideals of cosmopolitanism, it may become clear that the concept has developed over a long period of time and within various contexts that it is difﬁcult to capture a clear-cut meaning. However, all advocates of cosmopolitanism may agree on the equality of all human beings regardless of their belonging to certain society, culture, or ethnic group. They may, as well, contend that differences among humans are only socially constructed and should not have any bearing on the general approach to issues of justice and collective responsibility.

Therefore, the equal citizenship of all human beings in the global human community is built on the equality among them in regard to rationality and uniqueness. However, this citizenship comes with various responsibilities, including moral, political, and economic responsibilities to ensure the well-being of others and the just distribution of global resources. To explain more, the possible ground for cosmopolitanism may be either an egalitarian sense of justice or a mutual valorization of humanity. In the ﬁrst case, cosmopolitanism highlights the current status of global injustices and elaborates on what is owed to the less fortunate building on a speciﬁc understanding of justice. However, the latter ground builds on the equality of all human beings and the cardinal necessities for them to ﬂourish as peers. In both cases, the cosmopolitan ideal may be equated with a global sense of egalitarianism that is broader in scope than social egalitarianism (which is conﬁned only to a certain community) (Landesman 2011).

Clearly, the above historical and conceptual exploration of cosmopolitanism is necessarily biased in that it takes the Western premises and historical context for granted. Therefore, a non-Western religious and philosophical theoretical exploration of cosmopolitanism is necessary to establish a better picture that depicts the universal experience of being humans with many commonalities.

Ethical Considerations

Global Responsibility

To elaborate on the kinds of responsibilities that come with equal global citizenship, a cosmopolitan ideal may be classiﬁed according to its basic motivation (moral, political, and economic) and intended target (individuals, communities, or institutions) (Croce 2010; Kleingeld and Brown 2002). One should always bear in mind that theorists may not belong to a certain clear-cut formula of cosmopolitanism; they may all rather belong to a spectrum of preferences and ideals that overlap among them.

One difﬁculty when discussing the issue of responsibility is drawing clear lines and setting priorities for necessary interventions to improve the well-being of others. If cosmopolitanism is a global version of social egalitarianism (ensuring equal opportunity to ﬂourish for everyone who belongs to this society), then it becomes more difﬁcult to trace all the causes behind certain global phenomena and to evaluate the results of suggested interventions. The level of complexity at the global scale is so high that it may prove unattainable to fathom its dynamism. One example of such complexity may be the ﬁnancial crisis that afﬂicted the entire world in 2008 because of ﬁnancial decisions (and risk taking) in the US housing market. However, the repercussions of the crisis were felt all over the world for reasons that are not even clear for the economists, who since then are still speculating on the possible dynamics.

If all human beings are considered citizens of the same global society, then their relationships may be analyzed within the scopes of moral, political, and economic prisms. Therefore, when studying the cosmopolitan responsibility of human actors, theorists used these prisms to highlight the dynamics of human relations at the individual, cultural, and institutional levels.

Some theorists understand cosmopolitanism within the moral responsibility to improve the life of other human beings through advocating a more just society for everyone. To achieve that, they emphasize either the individual’s moral responsibility to improve the life of others, near or far. Others may advocate nourishing certain cultural sensitivities to the plight of others to mobilize the entire society to make a difference. The third possibility, it is speculated, is to ﬁrmly establish nongovernmental institutions, national and international, within just parameters to make a difference (Bernstein 2012).

On the other side of the responsibility debate, some theorists emphasize the centrality of political engagement at the global level to achieve a just global society. Some advocate democracy for all nations to ensure the political involvement of every human being in creating a more just world. This might be achieved either through the establishment of democracy in each nation, the reformation of international institutions to account to the well-being of everyone, or a few (if any) may call for a central global government that establishes a worldwide democracy (Buchanan and Decamp 2006).

Contrary to the above moral and political sensitivities, it seems that the only dimension of cosmopolitanism that does not attract similar debates among different people is the economical dimensions. Porous boundaries among nations for free trade elicit the least objection by the majority of people. However, free trade is the least defended model of cosmopolitanism among philosophers. For them, economic cosmopolitanism, in most cases, perpetuates the gradient of power among different nations and facilitates the exploitation of the most vulnerable.

Objections To Cosmopolitanism

Cosmopolitanism encounters many objections that are directed either to its justiﬁcation of global responsibility or to its practicality in the current international political scene. Opponents to the cosmopolitan ideal of global equality argue that cosmopolitan sentiments may interfere with national or patriotic responsibilities. They contend that the broader the responsibility is the less one is bound by his/her responsibilities toward those who are closer to him/her. This statist argument is mainly built on a contractarian understanding of national relationships and the ensuing obligation to reciprocity and solidarity among fellow citizens. Moreover, many oppose the cosmopolitan ideal because it contradicts state sovereignty and attempts to enforce an ideal that is seemingly above and more abiding than national interests. In the same vein, less developed and powerful states may become a target for the abuse by stronger nations because of the difference in power (Pogge 1992).

Furthermore, opposition to cosmopolitanism highlights the impracticality of the ideal and its possible abuse. It seems to many opponents that establishing a global government will open the door for a despotic state that is not accountable to any higher power. Others emphasize that a cosmopolitan responsibility that does not differentiate between compatriots and non-compatriots is too demanding to be achievable. Similarly, it seems unjustiﬁable to invest dire resources to develop certain technologies, for instance, and then let other people or states use it without paying their share in the development process or expenses. This puts one of the central modern ideals, namely, patenting and copyrights, into jeopardy.

Although these objections may sound valid, especially in regard to the difﬁculty of achieving the cosmopolitan ideal in the current political scene, many advocates defend the compatibility of cosmopolitan responsibility with other smaller scale responsibilities (Audi 2009). Some advocates attempt to dissociate cosmopolitanism from any aspiration to establish despotic global political system. They emphasize that nurturing a sense of global citizenship does not interfere with one’s reasonable responsibility toward compatriots.

While the economic dimension of globalization may be practically the least problematic among other dimensions, many theorists and philosophers contend that this dimension should be subordinate to a global framework of moral responsibility. Moreover, because of economic globalization, medical and pharmaceutical research crosses national boundaries. This research sometimes exploits those who are deprived of even minimal healthcare for the sake of those who can afford the developed interventions (Petryna 2009). Paying back to those who participated in the research raises many moral questions in regard to responsibility and justice especially that their communities will not have access to those interventions.

At the very least, some advocates of global moral and political responsibilities prefer to highlight how some health disparities are perhaps detrimental to national well-being and security (Lencucha 2013). Recent debates in Western countries on banning the entry of people coming from West African countries afﬂicted with the Ebola virus highlighted this national security dimension. Similarly, national security is frequently used as an argument in favor of humanitarian aid to other nations.

Disparities In Current Global Health

When taking the cosmopolitan ideal into consideration in discussing the current health status around the world, many issues may arise especially in regard to possible justiﬁcation of health disparities. Life expectancy at birth is one of the measurements used to evaluate the health of certain communities. It brings a great deal of emotional reactions to know that if someone is born in Africa he/she will be expected to live for only 40 years, while another person who is born is Europe will live for 80 years on average.

Similarly, when one in every ﬁve children born in Africa is expected to die before his/her ﬁfth birthday, it is difﬁcult to justify the disparity in childhood mortality rates using the absurdity of luck in a time of unprecedented scientiﬁc development. Therefore, it seems that the global disapproval of health disparities among various human groups, regardless of the distance that separates them, may be attributed to the fact the humans cherish health as necessary for a decent life. Put in a utilitarian language, health is cardinal to have access to different opportunities to thrive in any given human society (Daniels 2007).

However, in confronting these disparities, many questions arise to clarify the relevant issues.

The ﬁrst ethical issue is related to the concept of justice in health. Justice itself has many meanings and it is not easy to establish a global consensus around its meaning. Moreover, when the question of justice arises in the context of health disparities, its use becomes even more complicated: what is the meaning of just distribution of health? The answers may vary: justice is served when everyone in the pertinent society has the same health status as everyone else. However, such egalitarian health status does not take into consideration many factors that cannot be controlled (or may be unreasonable to change), such as the genetic makeup of every person, aging process, and personal choices in matters of eating and exercise, for instance. When the discussion is reﬂecting the global status of health, these factors exponentially increase in their scope and complexity: how is it possible to equalize the health of all human beings who live in incomparable environments within disparate circumstances (Dwyer 2005; Ruger 2006)?

However, other theorists have suggested that justice in health may be served through egalitarian access to medical care, or at least to basic care; both options bring even more complexity to the discussion. One obstacle to equal access to medical care is related to the current economic and societal disparities. Within these multidimensional disparities, improving health in developing countries would need, along with improving medical care, multifocal and parallel developments in education, infrastructure, and food security to only mention a few. This brings to the table the discussion of determinants of health at a global level.

Global Determinants Of Health

Bioethical discourse at the global level may beneﬁt from the already advanced study of social determinants of health at the local level, although such discourse has its own unique features. Social determinants of health are those factors that may compromise or improve human health and longevity but are not directly related to individual access to medical care and advanced medical technologies. These factors may include access to healthy nutrition, potable water, exercise, education, and decent living circumstances. These local determinants of health increase exponentially when considered within the current global dynamics and international relations. For instance, “structural violence” controls many facets of international relations that it affects the health of the most vulnerable populations on earth. Corruption in these relations has caused horrendous compromise to the health of many people not only through the unavailability of medical care but through avoidable deterioration in their living circumstances and exposition to preventable infectious diseases. Similar compromises to health have arisen over the past couple of centuries because of the environmental crisis and food insecurity in many parts of the world.

In confronting these determinants of health at a global level, many challenges arise that ﬁnding satisfying answers may become even more complicated. One challenge is how to address some of these factors: should it be by using generous humanitarian aid to ameliorate any given crisis in health or through addressing the underlying structural causes of that crisis? In the same vein, should the underlying rationale behind any suggested intervention be a compassionate charitable act or should it be a sense of mutual accountability of the plight of others, whether directly or indirectly? Therefore, when addressing health disparities among various nations (and within any given nation), should an ahistorical mindset of international responsibilities frame the discussion of global bioethics or should it be framed within a contextual-historical exploration of current circumstances? (Yamin 2010).

At A Practical Level

There are many factors that are bringing the issue of global health disparities to the forefront building on the cosmopolitan ideal. Many international organizations are working on the propagation of the cosmopolitan ideal to improve global health. Some of them are governmental institutions that depend on the cooperation of member governments in implementing certain interventions to improve health, such as the various organizations under the umbrella of the UN including UNICEF, UNESCO, and WHO.

Other nongovernmental organizations are taking the lead in improving the health and life circumstances of populations around the world, such as Doctors Without Borders, Human Rights Watch, and a host of other humanitarian organizations. Those organizations use the cosmopolitan ideal and equality among human beings as a compass for their work.

One of the major contributions to the cosmopolitan ideal in global bioethical discourse is the UNESCO Universal Declaration on Bioethics and Human Rights adopted in 2005. The Declaration was signed by the governments of member states and used the human rights discourse as a basis to establish a moral cosmopolitan framework to handle matters of health disparities. This Declaration takes into serious consideration the above-mentioned global determinants of health and attempts to address health disparities within the parameters of the cosmopolitan ideal (ten Have 2011).

Conclusion

In summary, this entry is intended to brieﬂy unfold the role of cosmopolitanism in shaping the current discourse in global bioethics. Although it is an old concept that developed over many centuries, it is still relevant to contemporary human society around the world. It highlights the equality of all human beings as members of the same universal community. Within this framework of equality, the discussion of responsibility, justice, and health disparities takes place. As a concept, it does not provide a deﬁnite answer to all moral dilemmas in that regard; however, it helps to rethink the current situation of health and its disparities through a different lens.

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