DFG Research Group 2104 at Helmut Schmidt University Hamburg http://needs-based-justice.hsu-hh.de

Setting limits to public health efforts and the

healthisation of society

Thomas Schramme

Working Paper Nr. 2015-03

http://bedarfsgerechtigkeit.hsu-hh.de/dropbox/wp/2015-03.pdf

Date: 2015-05

DFG Research Group 2104

Need-Based Justice and Distribution Procedures

1

Settinglimitstopublichealtheffortsandthehealthisationofsociety

ThomasSchramme

(May2015;finalversionpublishedin:zeitschriftfürmenschenrechte2015,9(2):50-

68. DFG Research Group 2104 “Need-based Justice and Distribution Procedures” (DFG Grants NU 108/4-1)

Publichealthsetsouttopromoteorimprovethehealthofthepopulation.Whereshould

itstopinsuchquest?ThisisthequestionIwouldliketoexploreinthisessay.Isubmit

thatifthereisnothresholdsettopublichealtheffortstherewilllikelybeevermore

"healthisation"ofourlives,asthereisnointernalstoppagewhenpursuingpublichealth.

Itisimportanttochallengehealthisation,becauseithasnegativeimpactonpeople's

livesandpotentiallytheeconomyaswell,asitunderminesindividuallibertyandgoes

alongwithopportunitycosts;hencetheneedforathresholdof"enough"population

health.Onereasonwhythereisnosuchinternallimitinpublichealtheffortsisdueto

thevalueofhealth.Sincehealthisdeemedtobeanintrinsicandaninstrumentalvalueit

seemsthattoimprovehealthisalwaysaworthypursuit.Anotherreasonforexpansion

ofstateactivityisthatpublichealthaimsnotjustatanimprovementoftheindividual

absolutelevelofhealthofcitizensbutalsoatacomparativelevelofhealththatisas

equalaspossiblebetweenpopulations.Sincetherewillalwaysbesomeamountof

healthinequalitiestherewillalsoalwaysbereasonstoimprovethehealthatleastof

somecitizens–hencetheinternallyunstoppableefforttohealthimprovement.

Apromisingtheoreticalaccountinsettingathresholdtopublichealtheffortsis

sufficientarianism.Itdeterminesalevelofwhatisenoughprovisionforpeoplesothat

theyhavesufficientlygoodconditionstoliveadecentlive.Sufficientarianismisatheory

ofjustice;itclaimsthatthesufficientlevelofprovisioniswhatweowetoeachother,

hencewhatcitizenscandemandasamatterofbasicrights.Sincepublichealthisa

politicaltask,itsremitshouldbebasedontheproperboundariesofastate's

responsibilities.Icontendthatsufficientarianismisinlinewithaliberalapproach,

althoughitis,inasense,aminimaltheoryofjustice.Invirtueoffocusingonabsolute

levelsthateachcitizenshouldbeabletoreach,itisnotaimedatequalizingtherelative

positionofcitizensanditlimitsthevalueofhealthinthepoliticalarena.So

sufficientarianismisnotaffectedbythetworeasonsforhealthimprovementmentioned

earlierandcansetlimitstohealthisation.

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Thepaperproceedsasfollows.First,Iwillintroducemyunderstandingof

sufficientarianism.Thisisimportant,asthereareseveraldifferentversionsofsucha

conceptionofjustice.Iwillthenfocusonmattersofhealth.Inordertoassessdifferent

healthpoliciesitisvitalforpublichealthinstitutionstobeabletosayinwhatsenseone

policyleadstomorehealthinthepopulation.Thisrequiresagradablemeasureof

health,ameasurethatdiffersfromthetraditionalpointofviewinmedicine,where

healthissimplytheabsenceofdisease.InthesecondsectionIexplaintheconceptof

healthinpublichealthanddiscusssomeofthechallengesitcontains,mostnotablyin

makingsenseofhealthasasinglemeasure.Iarguethatbecausewecannotmeasure

healthdirectlyweneedproxies,andthatthesealternativescalespointataneedfora

"currency",especiallywhenthinkingaboutjustice.InthethirdsectionIputthedebate

onjusticeregardingpopulationhealthinthecontextofjusticeinwelfarestates.This

wayofcontextualisingalsopointsatthewiderfocusofjustifiedstateaction.Iarguefora

sufficientariannotionofthepurposeofthewelfarestate,whichisgivenbytheideaof

inclusionofallcitizensintosociety.Publichealthinthisrespectaimsatsteeringthe

socialdeterminantsofhealthsothateveryonecanbeabletofeelasamemberofa

society.Inthefinal,fourth,sectionIelaborateonthecurrencyofpublichealthjustice.I

developtheoutlinesofaframeworkofhealth-relatedbasicneeds.Itisimportantto

alwaysseethesehealth-relatedneedsinrelationtootherbasicneedsofhumanbeings

aswell,suchasindividuallibertyandsociality,especiallywhenconsideringpublic

healthpolicies.

1.Sufficientarianism

Severalauthorstendtoassumethatthe"worldofjustice"isaltogetherdividedbythree

clustersoftheories:egalitarianism,prioritarianism,andsufficientarianism(Parfit1995).

Theythenarguefor,say,egalitarianism,byobjectingtooneoftheothertheories(Casal

2007).Butitseemsmoreadequatetofirstconsiderthecontextofjusticethatisbeing

discussed.Inthecaseunderdiscussioninthispaper,publichealth,thecontextissetby

institutionsofthewelfarestate,soourquestioniswhichtheoryofjustice,ifany,would

besuitableasatheoryofthejustwelfarestate.Wearedealingherewitharealsiteof

socialjustice,notwithapurelytheoreticalworldofjustice.

Itisalsodebatablewhetherauthorswhoargueagainstonetheoryofjusticethereby

automaticallysupportanotherone.Thisonlyworksiftherearejustthesealternatives

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andiftheyareindirectcompetition.Butnotallaccountsofsocialjusticefollowthe

samelogic;mostnotablyforourpurposesthereisanimportantdifferencebetween

comparativeandnoncomparativejustice.Isubmitthatsufficientarianismfollowsa

differentlogicthanegalitarianism,sinceitisanaccountofnoncomparativejustice,

whereasegalitarianismisatheoryofcomparativejustice.Sufficientarianism,invirtueof

focusingonwhatisenough,isconcernedwithdeterminingwhatisduetopeopleonthe

basisofasetstandard,notonthebasisofwhatotherpeoplehave.Incertainversions,it

mayevenallowforegalitariandemandsinadditiontosufficientarianones;atthevery

leastsufficientarianismisnotnecessarilyindirectcompetitionwithegalitarianism.

JoelFeinbergdescribesthedifferencebetweencomparativeandnoncomparativejustice

thus:"Inallcases,ofcourse,justiceconsistsingivingapersonhisdue,butinsomecases

one'sdueisdeterminedindependentlyofthatofotherpeople,whileinothercases,a

person'sdueisdeterminableonlybyreferencetohisrelationstootherpersons.Ishall

refertocontexts,criteria,andprinciplesoftheformerkindasnoncomparative,and

thoseofthelattersortascomparative."(Feinberg1974,298)

WecandescribeageneralideaofjusticefollowingFeinberg'saccount:ForallXthat

fulfillcriterionY,Zisdue.Thiscanbespecifiedinvariousways.Forinstance,atheoryof

healthjusticemightclaimthatforallcitizenswithafamilymemberwhodeveloped

breastcancershouldhaveaccesstofreeadditionalearlydetectionprograms.This

wouldbeanoncomparativeprincipleofjustice.Alternatively,wemightholdthatonly

5%ofthepopulationwiththehighestriskofgettingbreastcancershouldgetsuch

access.Whetheronegetsadditionalscreeningforfreeinthissecondscenariodepends

onthehealthriskstatusofotherpeople.Itisthereforeacomparativeprincipleof

justice.

Sufficientarianismisconcernedwiththesituationofeachperson,anditdemandsthat

everyoneshouldbeaboveacertainthreshold.Whatisduetoeachperson,in

sufficientarianism,isdeterminedbythestandardsetbythethresholdof"enough";

hencewhatisduetopeopleisnotdeterminedbytherelationsofanypersontoanother

person–saveforcomplicatedcases,whichIignoreforthetimebeing.These

complicationshavetodowiththefactthatwhatisenoughcanbebasedonrelational

aspectsinsofarasthelevelofdevelopmentwithinasocietymightinfluencethelevelof

sufficiency.Hencewhatisduetopeoplemightbepartiallyduetowhatothershave.Yet

thisisaderivationalorindirectaspectofsocialjustice.

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Theremightbeadditionalconcernsofjusticewherecomparativeprinciplesare

considered,especiallyincompetitivescenarios.Levellingtheplayingfieldofteninvolves

comparativeaspects,suchasthelevelofskillsofcompetitorsortheirrelative

advantage.Similarly,theremightbeconcernsofcomparativejusticewhenconsidering

thelevelofhealthofcitizens.Forinstance,wemightholdthatitisunjustifrichpeople

livelongerthanothersbecausetheyhaveaccesstobetterlivingconditionsandmore

advancedhealthcare.Sotheremightbeegalitarianconcernsinadditionto

sufficientarianones.Thismightespeciallybefittingbecausehealthseemstohave

competitiveaspects,whicharesummarizedinitsinstrumentalvalue.

Althoughitisnotmyremitinthisessaytodiscussthemeritsofegalitarianisminhealth

careorpublichealth,Ineverthelesswouldliketostressthatsomeoftheegalitarian

concernsmaybesufficientlydescribedeitherbyasufficientarianperspectiveordealt

withbyothermeansthanreallocationofresources,welfare,oraccesstoadvantages.

Sufficientarianismcanoptforanequaldistributionofgoods,becauseitmighthappen

thateveryoneisowedacertaingood.Equaldistribution,inthesecases,isaconsequence

ofanoncomparativeprinciple.Also,someegalitarianconcernsmightbedealtwithby

puttingupfencesbetweendifferent"spheresofjustice"(Walzer1983).Ifaccessto

healthcareortohealthyenvironmentswerenotbasedonabilitytopay,therewouldbe

fewerconcernsaboutrichpeopletendingtolivelongerorsimilarinequalities.

Thereareseveralobjectionstosufficientarianism,someofthemarebasedon

confusions,othersaremoreimportant.Forinstance,someauthorsclaimthatthe

thresholdofsufficiency,whichisusuallydescribedasaimedatsecuringadecentlife,

impliesthatalifebelowsuchastandardisnotworthliving(Segall2014,2;Ram-Tiktin

2012,343).Thisiswrong.Whetheraliveisworthlivingnecessarilyisbasedon

subjectiveevaluation.Sufficientarianism,incontrast,determinesexternalconditionsfor

adecentlife,henceisnotbasedonsubjectiveevaluation.Obviously,alifecanbenot

worthlivingforapersonwayabovethethreshold,andallthatsufficientarianismclaims

isthatalifebelowthethresholdisfacingbadorindecentlivingconditions.

Anotherobjectionthatmanyauthorsareconcernedwithisthatthethresholdsetby

sufficientarianismwouldneedtobeeitherambiguousorarbitrary(e.g.Arneson2000,

56;Casal2007,312ff.)Arbitrarinessisofcoursetheverycontradictionofjustice.But

surelythereisanimportantdifferencebetweenindeterminacyandarbitrariness,which

ishoweveroccasionallyconfused(Segall2014,2).Ifthethresholdshouldprovetobe

indeterminateorambiguous,thisisnotunderminingitsrationalstatuswithinatheory

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ofjustice.Whatisleftindeterminateinatheoryofjusticecanbedeterminedbyreal

decisionswithinsociety.

Again,someauthorscomplainthatsufficientarianismdoesnotdealwithunjust

conditionsabovethethresholdandimpliesdubiousallocationsbelowthethreshold,

becauseresourcesmightbe"wasted"ontheaimofbringingpeopleuptothethreshold.

Thisobjectionisbasedonconfusion,althoughithastobesaidthatsomesupportersof

sufficientarianismarealsoguiltyofit.Itreliesonaninadequatedescriptionofthevery

purposeofsufficientarianism,namelyasallegedlymakingcomparativeevaluations

betweendifferentpossibleallocationsofgoods.Sufficientarianismallegedlyassumes

thatitmattersmorethatpeoplehaveenoughthanotherconcerns,orthatpriority

shouldbegiventothebadlyoff(Freiman2012,26;Segall2014,1;Huseby2010,180;

Benbaji2005;cf.Widerquist2010).Thisiscorrectinasense,butnevertheless

inadequate.Itiscorrectinsofarsufficientarianismindeedclaimsthatitisimportantthat

peoplehaveenough;butthisdoesnotimplythatitmattersmorethanotherthingsor

thatindeedotherconcernsofjusticedonotmatteratall.Therecanbeachangeinthe

sortsofreasonswhenweargueaboutmattersofjustice,andsufficientarianismisbased

onparticularreasons(Shields2012).Theyconcernwhatisajustdistributionofgoods,

nothowitcomparestootherpossibledistributions.Thelatterrequiresreasonsthatgo

overandabovetheclaimsofsufficientarianism,forinstanceregardingtheaggregation

ofdifferentunitsofgoods.

Inaddition,thereisunfortunatelyatendencyinthephilosophicalliteraturetothinkin

numbers(Parfit1995;Crisp2003).Wethenfindpoliticallyandeconomicallyhampered

debatesondifferentallocationsoffixedamountsofgoods,whicharesupposedtobe

distributedaccordingtodifferentprinciplesofjustice.Thesedifferenthypothetical

scenariosofallocation–whichareofcourseremovedfromtherealworldofawelfare

state–arethencomparedandphilosophers'intuitionsabouttheirjustnessarecalled

upon.Butthiscannotbethewayforwardinthinkingseriouslyaboutrealissuesof

justice.

Insum,inthissectionIhavedefendedaversionofsufficientarianism,whichisa

noncomparativetheoryofjustice.Itdoesnotruleoutadditionalcomparativefacetsof

justice–itissimplynotconcernedwiththeseasamatterofphilosophicaltheory.Sucha

sufficiencyapproachaimsatsettingathresholdofsocialjustice,ofwhatisenough.

Surelycitizensmightwanttosecureforeveryonealevelofprovisionthatisaboveof

whatisenoughonanoncomparativebasis,forinstancebecausetheywanttoliveina

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veryequalsociety.Sufficientarianismdoesnotunderminesuchadesire,itsimplystates

thatthisisnotitsconcern,anditremainstobeseenwhethersuchanadditionaldemand

ofdistributionalequalitycanbebasedonphilosophicalarguments,orwhetheritis

moreofamatterofpoliticalpreference.Whethertheaccountdefendedhereisalso

substantiallyminimaldependsonthelevelofprovisionsetbythethreshold.Thiswillbe

discussedbelow.Sinceweareconcernedwiththecontextofhealthcareandthesocial

determinantsofhealth,thefirstimportantissuethatpartiallydecidesthelevelof

sufficientprovisionisthenotionofhealth.

2.Theconceptofhealthinpublichealth

Itisimportanttounderstandthattheconceptofhealthisunderstoodinaspecialsense

inpublichealth.Inmedicine,healthiscommonlyunderstoodinanegativefashion,as

theabsenceofdisease,orasmedicalnormality.Thisisaminimalandabsoluteconcept

ofhealth.Apersoniseitherhealthyornot,therearenogradesofhealth.Inordertobe

regardedashealthy,itismerelynecessarynottobeinanypathologicalcondition.Tobe

sure,thereareattemptstoconceptualisehealthinapositiveway,forinstanceinthe

well-knownformulationoftheWorldHealthOrganisation:"Healthisastateofcomplete

physical,mentalandsocialwell-beingandnotmerelytheabsenceofdiseaseor

infirmity".Yet,thisdefinitionhashadnoimpactonmedicaltheoryorpracticeandhas

actuallybeencriticisedforitslackofdistinctionbetweenwell-beingorhappinessand

medicalhealth(Callahan1973).

Theconceptofhealthinpublichealthdiffersfromthismedicalviewpointinseveral

importantrespects.Itisarelativeorgradablenotion,anditappliestogroupsor

populations.Aperson(orgroupofpersons),inthisperspective,canbemoreorless

healthythananotherperson(orgroupofpersons).Thismightevenbethecaseifthere

isnodiseasepresent;peoplecanbelesshealthythanothersinapublichealth

perspectivesimplybecausetheybelongtoagroupthatisstatisticallymorelikelytofall

ill.Consequently,itcaneasilyhappenthatfromthispointofviewweseeproblematic

conditionsoverandabovetheabsenceofdisease.Afterall,somerisksofdiseaseare

constantlypresent,andtheycanbetargetedbystateaction.Becausesocial

determinantsofhealthareseeninsuchcloserelationtomedicalconditionsitisbuta

smallsteptoawelfarenotionofhealth(Venkatapuram2011).Thisisaninterpretation

ofthenotionofhealththatincludesconditionsthatareinternalandexternaltothe

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personundertheumbrellaofhealth,suchasbeingabletoexperiencenatureorhave

occasionsforrecreation,whicharenotseenthemselvesashealthconditionsin

medicine.

Usually,publichealthexpertsfocusonparticularsocio-economicgroups,forinstance

unemployedpersonsorsinglemothers.Sowhenepidemiologistsrefertopopulation

healththeyrefertoastatisticallyaggregatedsumofindividualhealthtraitsorhealth

statuses.Thewaythesegroupsorpopulationsaredetermineddependsontheparticular

purposeofastudy.Ultimatelytheseconsiderationsdependonhypothesesaboutsocial

orsocioeconomicdeterminantsofhealth,or–touseanotherexpressionfamiliartoa

publichealthperspective–the"causesofcauses"(ofhealthstatus).Hence

epidemiologistsendupwithfindingsaboutpossiblecorrelationsbetweenparticular

circumstantialaspectsofcitizensandtheirhealthconditions.Findingsmaybesought

regardingsocio-economicaspects,suchasincome,educationalbackgroundorgender,

orbehaviouralaspects,suchaslifestyleanddiet.Withthesestatisticalcorrelationsitis

possibletomakecomparisonsbetweenpopulationsregardingtheirhealth,evenonan

internationallevel.Obviouslyitisalsopossibletocomparedifferentpoliciesintackling

thosepossibleinequalities.Inmorepopularpublications,publichealthscholarsthen

usesimpleslogans,suchas"inequalityisbadforyourhealth",or"uneducatedpeople

dieyounger",whichonlymakessensefromapopulationperspective.Suchacollective

perspective,though,itneedstobestressed,tendstoignoreaspectsontheindividual

level,forinstanceindividualresponsibilityforhealthstatusandalso–moreimportantly

fortheworriesthatdrivemyendorsementofsufficientarianism–individualrightsthat

mightconflictwithpoliciestoimprovethehealthstatusofsomepopulations.

Thecomparativeperspectiveofpublichealthdepends,uptoapoint,onthefactthat

peoplecanhavecertaindispositionstofallill.Asmoker,forinstance,ismorelikelythan

anon-smokertosufferfromanylungdisease.Apersonwhoworksoutandisgenerally

fitterthanothersislesslikelytocatchacoldthanothers.Epidemiologicalresearchalso

establishescorrelationsbetweenexternalenvironmentsandhealthconditions.For

instance,adarkandunpleasanthome,oraverystressfulworkenvironment,canall

enhancethechancetofallill.

Inordertodistinguishgradesofhealththeperspectiveofpublichealthneedsmeasures

ofcomparison.Inwhatrespectcanaperson(orgroup)behealthierthananother?What

maybecriteriafordetermininggradesofhealth?Thesechallengesregardingthe

measurementoflevelsofhealthareverydifficulttosurmount.Thisisbecausehealthis

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acomplexaggregationofdifferentaspects.Wecanonlycomparepeopleincertain

respects;wecanneversaywhethertheyaremorehealthythanotherstoutcourt

(Hausman2012).Issomeonewithanirritablelungbutarobustpsychelesshealthythan

amarathonrunnerexperiencingbullyingatwork?Suchquestionscannotbeanswered

unlesswefocusoncertainaspectsoffunctioning.Publichealthusuallyworkswithonly

someparticularhealthaspects,suchasmentalresilienceorphysicalfitness.Italsorelies

onproxiesofthesecriteria,sincetheycannoteasilybedirectlymeasured,hencepublic

healthforinstancecollectsdataaboutfrequencyofvisitsatadoctororthenumberof

daysonsickleave.Finally,thereisaproblemofcollectingdatainepidemiology,which

focusesonpopulations,notindividualpersons.Epidemiologyrequirescertain

abstractionsforpurposesofgeneratingstatisticaldata.Acommonstatisticalmeasure

forcomparinghealthofcertaingroupsislifeexpectancy.Obviouslyhereitisnot

individualhealththatismeasuredandcomparedbutaheavilymodifiedproxyforhealth

conditions.

Ibelabourthispointaboutproblemsinmeasuringhealthbecauseitisanissuethatalso

affectsanyattempttointroducethresholdsofenoughhealth.Henceitisachallengefor

mysufficientarianpointofviewaswell.Still,itisasurmountableproblemafterall,

becausepublichealthdoesnotdirectlypromoteindividualhealth,whichwouldbetoo

difficulttomeasure.Itratheraimsatprovidingthenecessarymeansinordertobeable

toliveahealthylife.So"enoughhealth"willtranslateintosomethinglike"enough

resourcesandcapacitiestoliveaminimallydecentlifeinrelationtohealthaspects".The

"currency"(Cohen1989)ofcashingoutthelevelofhealththateveryoneshouldbeable

toreachasamatterofsocialjusticewithinasufficiencyapproachneednotbedifferent

fromanycommonpublichealthperspective.Onesuchpossiblecurrencywouldbefor

instanceacapabilitiesapproach(Venkatapuram2011).Thedifference,though,tothe

ideaofhealthpromotionwefindinpublichealthisthatsufficientarianismaboutpublic

healthsetsaminimumthreshold,whichisusuallynotdiscussedwithinrecent

approachesofpublichealth,atleastinrichcountries.Here,promotionofhealthusually

allowsforimprovementsoverandabovethepreventionofindecenthealth-related

livingconditions,becausehealthisunderstoodasaconditionsthatismorethanjustthe

absenceofdisease.

Thefactthatpublichealthallowsforgradesofhealththereforeopensthepossibilityto

discusshealthpromotioninawaythatincludesenhancinghealthoverandabovethe

absenceofdisease.Thisisexactlytheareawheretheworriesabout"healthism"begin.

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Health,understoodinapositivesense,likeinthedefinitionoftheWHO,doesnothave

aninternalnormativestoppageorthresholdofadequatehealth.Morehealthisalways

betterthanless.Foregalitarians,morehealthisalsorequiredforsomegroupsasa

matterofjustice.Whatismore,theimprovementofhealthisnotmerely,andmaybenot

evenprimarily,amatterofimprovingtheinternalresourcesofaperson,suchas

staminaandnutrition,butalsoofthesocialdeterminantsofhealth,suchasqualityof

workenvironment,accesstoleisurelyactivitiesandsoon.Wecanthinkofmanywaysto

–ifonlyindirectly–improvehealthdispositionsofcitizensbyimprovingtheir

environmentaswellaschangingtheirlifestyles.Sothepossiblescopeforpublichealth

interventionsisverywideindeed.Ifwenowaddthecurrentvaluethatisattachedto

healthinmanysocieties,wecanseehowthisemphasisonhealthpromotionopensthe

doorforworriesaboutpaternalisticinterventions,whichareevenmoreworrisomeif

interventionsareduetostateaction,orlegalmeasures.Onewaytoavoidthese

problemswouldbetointroduceathresholdof"enough"health,henceasufficientgrade

ofhealththateverycitizenshouldbeabletoreach,withoutoverreachingthetargetof

adequatehealthpromotion.

3.Theaimsofstateaction

Publichealthisapoliticaltask.Itispartoftheremitofeverywelfarestate.Inorderto

understandtheproperroleofpublichealthitisthereforehelpfultodiscussitinthe

widercontextofstateaction,particularlythepurposeofawelfarestate.More

concretely,wemightwanttophrasethequestion:Howmuchofaconcernforthestate

isthehealthofthepopulation?Theanswertothisparticularquestionisrelatedtothe

moregeneralquestionregardingtheaimsofthewelfarestate,whilethislatterproblem

isagainrelatedtotheevenmoreabstractnotionofsocialjustice.Weprobablywould

nothaveanywelfarestateinstitutions,suchasschools,unemploymentbenefits,or

publiclyfundedhealthcare,ifwewouldnotdeemitsprovisionamatterofsocialjustice.

Sowhatlevelofwelfarestateprovisiondoweowetoeachother?Iunderstandthese

questionsnotmerelytoposeproblemsofnormativepoliticaltheoryalone,butIwould

liketodiscusstheminthecontextoftherealworldsofwelfarestates.Thiscommitment

toamorerealistpoliticaloutlookadmittedlyrequiresmoremethodological

considerationsthanIcandeliverinthispaper(butseeWaldron2012,forsome

interestingdiscussion;cf.Schramme2008).

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Ibelieveitisimportanttokeepthementionedcontextofrealwelfarestatesinmind,

especiallywhendiscussingpublichealth,whichtargetsnotdirectlythehealthof

individualcitizens,butthesocialdeterminantsofhealth.Forthepurposesofmy

argumentIwillassumethataminimalistunderstandingofthepurposeofthewelfare

stateistodemandtheinclusionofeverycitizenintosociety.Thisisitselfahighly

abstractrequirement.Thebasicideaisthateverycitizenshouldbeincludedasa

memberofasociety.Itisfocusedontheabsolute,ornoncomparative,socialstatusof

citizens:beingamemberofsociety.Suchanabstractdescriptionallowsforvarious

concreteprovisionsanddifferentemphasesonvaluesthatunderlietheideaofinclusion.

Hencetherecanbevariantsofwelfarestates(Esping-Andersen1990;Kaufmann2013).

Also,whetherpeopleareabletodeemthemselvestobemembersofaparticularsociety

canrequiredifferentprovisionsrelativetothelevelofdevelopment.Forinstance,ifthe

majorityofpeoplewithinasocietyhaveaccesstocomputersandmodernmedia,it

mightbepossiblethatsomecitizens,whocannotprovideforaccesstothesemediaby

themselves,areexcludedfromsocietyinthisrespect.Morepertinenttoourdiscussion,

inasocietythatlivesforanaverageof80years,itmightbeasignofpossibleexclusionif

somepeopledieintheirfiftiesduetotheirlivingconditions.Soalthoughthereisan

absolutethresholdsetbytheideaofinclusion,theexactlocationofsuchathresholdcan

berelativetothesocietalandhistoricalcontext.

Tofocusontheideaofsocialinclusioninrelationtotheaimsofthewelfarestateisnot

anunusualidea.Infact,itcanbefoundinoneofthemostadvancedandrenowned

theoriesoftheoriginsofthewelfarestate:ThomasH.Marshall'sCitizenshipandSocial

Class.Marshalldistinguishesbetweensocialrightsaccordingtotheir(idealized)

historicaldevelopment.First,civilorlibertyrights,whichareoftencallednegative

rights,becausetheyrestrictthejustifieduseofstateandsocietalpower;second,

politicalrights,suchastherighttovoteandgainpoliticalpower;third,socialrights,

whichentitlecitizenstogainingaccesstosocialgoods.Together,theexpansionofrights

canbeinterpretedasanincreasinginclusionofcitizensunderthenotionofcitizenship.

Socitizensbecomefullmembersofsociety(Marshall1950,p.6;cf.Waldron1993;

White2003,p.6).Theaimofwelfarestateinstitutionsistosafeguardcitizens'rightsby

preventingexclusion.Thelevelofsuchprovisionisconstantlytobedebatedwithin

societyandcannotbesetbyaphilosophicaltheoryofjustice.Welfarestatesare

thereforesitesofstrugglesbetweendifferentconceptionsofjustice,wherethereisno

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onecorrecttheoryofjustice(cf.Titmuss1965,p.124).Still,theoreticalconsiderations

regardingaminimalthresholdmightbepossible.

Whatmighttheabstractpurposeofinclusionmeanforpublichealth?Theanswertothis

questiondependsontheactualrequirementsoflivingaminimallyhealthylife,henceat

leastpartlyonempiricalfindings.Forinstance,toprovidesuchnecessarymeanswill

haveeducationalaspects,suchasinformingcitizensaboutthreatstohealthandhow

theycanimprovehealthdispositions.Morespecifically,healtheducationwillinvolve

informationaboutnutrition,stressandunhealthylifestyles–ingeneralsucheducation

willaimat"healthliteracy"(Kickbusch2001).Providingthemeansforinclusionwill

alsohavecircumstantialaspects,suchasprovidingaccesstorecreationalactivity,for

instancebybuildingparks,orprotectionfromhazardoussubstancesandepidemicsby

wayofhealthandsafetyregulationsandlegislation.Allofthesemeasuresaimata

minimumlevelofenablementofaminimallyhealthylife,whichallowscitizenstofeelas

membersofsociety,incontrasttoimprovingpopulationhealthoverandabovesucha

threshold.

Notethatthissufficientarianperspectiveonpublichealthisdifferentfromthe

influentialaccountbyRuthFadenandMadisonPowers(2006).Theyseethepointof

justiceinrelationtopublichealthastorequire"ensuringforeveryoneasufficient

amountofeachoftheessentialdimensionsofwell-being,ofwhichhealthisone"(p.9).

WhereasIagreethatitisimportant,whenconsideringmattersofpublichealth,tofocus

onmorethanjustintrinsichealth,namelyalsothesocialdeterminantsofhealth,I

disagreewiththeirfocusonwell-being.Thestate–viaitspublichealthinstitutions–

doesnothavethetaskto"improvehumanwell-beingbyimprovinghealthandrelated

dimensionsofwell-being"(ibid.,p.10).Accordingtomyview,publichealthmeasures

aimatprovidingthenecessarymeanstoenablepeopletoliveaminimallydecentlife,

whichisabstractlyunderstoodasamatterofinclusioninsociety,notasamatterof

well-being.Certainlythereareaspectsofhumanwell-beingthatweneedtotakeinto

accountwhenthinkingabouthealthandsocialinclusion,forinstancebasichuman

needs.Butwell-being–nevermindtheconstantimprovementofwell-being–isnotthe

targetofstateactionorthefocusofaconvincingtheoryofjustice.

Afittingexampleofasufficientarianpublichealthmeasurethatstayswithinthelimitsof

enoughhealthisthepublicfundingofschoolsmeals.Acertainamountoffoodperdayis

anecessaryrequirementforhumanbeingstoliveahealthylife.Anotheraspectof

havingschoolmealsisthecollectiveexperienceofpupils.Tobeexcludedfromschool

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dinnersforeconomicreasonsnotonlymeansverylikelytobelessadequatelynourished

fortheaffectedkids,butalsoimpliesnottobepartofagroupmakingavaluable

experience,maybewithfurthereffectssuchasbeingstigmatisedthatmighthavelong-

termconsequencesregardingpsychologicalhealthaswell.Nowobviouslythesemeals

couldbeprovidedindifferentways.Theycouldleaveachoicetostudents,sothatthey

canpickfromseveraloptions,ortheymightleavenochoice,forinstancebecauseofa

worrythatsomekids–possiblysufferingfrom"healthilliteracy"–mightalwayschoose

thelesshealthyoption.Thismightleadtootherconsiderations:Maybeseveraloptions

couldbeallowedbutthesemightnotbetargetedatkids'preferencesbutatthe

nutritionalvalueofthechoices.Sothereisscopeformorethansufficientarianchoices

byattemptingtoenhancehealthasmuchaspossible.Sufficientarianism,incontrast,

wouldaimatmakingschoolmealsapleasantexperienceforallchildren,notamatterof

thebestpossiblenutritionaloutcome.

Screeningprograms,whichareoftenusedaspublichealthmeasures,aremorecomplex

cases.Strategiestoencouragecitizens,especiallyhigh-riskgroups,toenrolinthese

programs,candifferenormouslyintheirintensity.Ifworriedcitizenswouldnotbeable

toparticipateatallintheseprecautionarymeasuresforfinancialreasons,despitethe

potentialseverityofadetectabledisease,thiswouldbereasontoarguethattheycannot

feelaspartofasociety.Afterall,notbeingabletotacklesuchhealthrelatedworries

impliesthatsocietyapparentlyseespoorpeople'shealthandfearsasofminor

importance.Soaccesstosuchscreeningprogramsforeachcitizenseemstobe

demandedbyasufficientarianaccountofpublichealth,thoughnotanylevelofsuch

provision,forinstancethelevelofmedicalsurveillancearichandworriedpersonmight

chose.Also,attemptstocompulsivelyguaranteefullandincessanthealthrelated

informationtoallcitizens,ortomanipulatelessworried–somewouldsay:careless–

citizensintoenrollingonsuchprogramsisadifferentmatter,anditisnotjustifiedona

sufficientarianbasis.

4.Sufficientarianismabout(population)health

SofarIhaveofferedabriefexplanationofthegeneralaimofsufficientarianism,which

is,tomymind,theinclusionofallinsociety.Everybodyshouldbeamemberofsociety

andnocitizenshouldneedtofeelexcluded.Ihavealsohintedattherequirementfora

"currency"ofsufficientarianismabouthealth:Wehavetodetermineinwhatwaywe

13

shouldassessthelevelofenoughhealthforall.Inthisfinalsection,Iwouldliketo

exploreinmoredetailwhatthecriteriacouldbeforcashingoutsufficientarianismabout

populationhealth.Thiscanfurtherhelpinrestrictingtheproperscopeofpublichealth

interventions.

AsIhaveexplainedinanearliersection,wecannotdirectlytargetthehealthofpeople

bypublichealthmeasures.Rather,theseinstrumentsaimatthecausesofthecausesof

disease,henceatdispositionalaspectsofthehealthstatusofpeople.Publichealthis

mainlyconcernedwiththecircumstancesofchoicesthatmighthaveanimpacton

health.Ihavesaidearlierthatonesuchcircumstanceishavinginformationaboutthe

possibleconsequencesofcertainlifestyles,abouthealthdangersduetohabitssuchas

smoking,orinadequatediet,andsoon.Anothercircumstanceisbeingabletoaccess

recreationalactivities,toavoidpermanentstress,noise,darkness,dampness,pollution,

etc.Ageneraldescriptionofthegoalofpublichealthmightthereforebethatitaimsat

providingthenecessarymeansforeveryonetobeabletomakehealthychoices,notto

actuallymakepeoplehealthy.Thelevelofindividualhealththatcitizenspursue,howfit

forinstancetheywanttobe,isuptothem.

Thethresholdwewouldprobablyconsiderfirstwhenthinkingaboutarestrictionof

publichealthmeasuresisthetraditionalmedicalnotionofhealthasabsenceofdisease.

Afterall,thisisaminimalnotionofhealth,asIhaveexplainedabove.Yet,sincepublic

healthaimsathealthdispositions,notathealthdirectly,almosteverychangeinthe

circumstancesofchoicemightdecreasetheriskofdisease.Soevenif"merely"the

avoidanceofdiseaseisouraim–whichlookslikeaminimalistgoal–wehavenot,in

virtueoftargetingthecircumstancesofrisksfordisease,restrictedthescopeof

intervention,afterall.

Onewayforwardforsufficientarianismaboutpublichealthwillbetoacknowledgethe

valueofhealthasanelement–butonlyoneelement–ofadecentlife.Therearelow

levelsofhealththatareperfectlyincongruencewithlivingadecentlife,andthereare

risksofdiseasethatareworthtakingbecauseofotheraspectsoflivingagoodlife.

Healthisnotusuallyouronlyorevenourmajorconcernwhencontemplatinghowto

live.

Sowearethrownbacktothemoregeneralnotionoftheconditionsofadecentlife.

Sufficientarianismoughttocashoutthisideainaminimalistsense.Ihavemostofthe

timeused"decentlife",insteadof"goodlife",toalludetotheminimalistagenda.Now,a

decentlifeseemsatleasttorequiretheabilitytofulfilbasicneeds.Sothismightbethe

14

startingpointforintroducingacurrencyofsufficientarianism.Indeed,Ibelievethatthe

mostpromisingwayforwardforsufficientarianismisbyconsideringtheconceptof

need.Admittedly,theconceptofneedisnotverypopularinethicsandpolitical

philosophy.Manydeemittooflexibletotellussomethingofsignificanceaboutthe

decentlife.Itseemsthateveryfancywishseemstobeasuitablecandidateforbecoming

aneed.Ibelievethisworrytobewrong,andwillthereforebrieflydiscussthesignificant

differencebetweendesiresandneeds.Inaddition,needsseemtobetheproper

candidateforourconcernhere,becausetheyusuallycomealongwithapowerfulclaim.

Afterall,weareconcernedherewithissuesofsocialjustice,orwhatweowetoeach

other.Ifwesaythatweneedsomethingweexpressthatitsprovisionisurgent,thatwe

cannotdowithoutit.Wethereforerefertoapotentiallyoralreadyharmfulsituation.

Basicneedsareabsoluteinthattheirdeterminationdoesnotrequireinterpersonal

comparison.Humanbeingshavebasicneedsinvirtueofbeingpersons.Iftheseneeds

cannotbefulfilled,thenpersonssufferseriousharm(Thomsom1987;Wiggins1985).It

isimpliedthatnoteverydiseaseisposingathreattobasichealth,hencetobasichealth-

relatedneeds.Thisideastandsincontrasttopopulartheories,suchasNormanDaniels's

(1985,p.32),whichseerequirementstothemaintenanceandrestorationof(negative)

health,i.e.theabsenceofalldisease,asaninstanceofhealth-careneeds.

Isubmitthatpublichealthshouldaimatprovidingthenecessarymeansforbeingable

tofulfilbasichealth-relatedneeds.Inordertodiscusssuchabsolute,basicneedsof

people,weshouldbecleareraboutthedistinctionbetweeninstrumentalandbasic,or

fundamental,needs.First,hereisageneralanalysisoftheconceptofneed:AneedsXin

ordertoφ.Notethattherecanbenon-normativeusagesof"need",forexample:"In

ordertoconductelectricityanelementneedsafreeelectron"(Thomson1987,p.3).Iam

interestedinthenormativeuseonly,sinceIwanttohighlighttheconnectionofneed

andlivingadecentlife.Thenon-normativeuselacksthepracticalnecessityIam

interestedin,whichistheurgencyoftheclaim.Incontrast,peoplewanttoexpressthat

thereissomethingharmfulhappeningtothemwhentheyareseriouslyill.Henceweuse

theterm"need"normativelywhenwesay:"Ineedtobeminimallyhealthy."

Withthehelpofthegeneraldefinitionofclaimsofneedwecannowdistinguish

instrumentalfromfundamentalneeds.Aninstrumentalneeddependsonthespecific,

possiblyidiosyncratic,goalsandaimsofthepersoninquestionwhileafundamental

needisnotderivedfromsuchspecificaspects.Forinstance,apersonmightsay:"Ineed

£100tobuythatcoat",butitisaneedthatdependsonherhavingtheaimtousethecoat

15

foraparticularpurpose.Itispossibletochallengetheactualneedforthatcoat.The

moneyisjustnecessaryforthegoal–togetthecoat–buttheachievementofthegoal

itselfisnotnecessarilysomethingneeded.Thepersonintheexamplewouldhaveto

explainwhysheneedsthecoat.ToanswerthequestionwhyapersonneedsXistosay

somethingaboutthenormativesignificanceofthegoalφ,whereXisanecessary

conditionofitsachievement.Thegoalcouldbeseenasalwaysreferringtoanaspectof

well-being(cf.Gustavsson2014,p.30),butwhereneedsgainurgency,Isubmit,iswhere

somethingisneededtopreventharm;itisthereforeanegativeperspective,focusingon

theavoidanceandeliminationofharm.Thisjustificationofneedscangoonuntilit

reachesapointwhereonecannotgiveanyfurtherreferencetoamorebasicgoal,such

asprotectionfromcold,butonlyassertthatonejustcannotdowithoutit,i.e.thatone

willbeseriouslyharmedwithoutX.Thereforetheseneedsarefundamentalorbasic

needs.

Basicneedsarespecialbecausetheirfulfilmentisnecessaryfortheavoidanceofserious

harm.Butnowthequestionisofcoursewhatconstitutesseriousharm.Wiggins

suggeststhatitisrelativetoculturalbeliefsconcerningharm.Anexample,partlydrawn

fromhisimportantwork,isthatoflackingclothes,whichwouldbeaseriousharmin

most,arguablyall,societies.Thomsondiscussestheconceptofharmatlength,butI

hopewecandowithouthisanalysis,sinceIdonot,forthepurposesofthispaper,want

tothoroughlyclarifytheconceptofneedingeneral,butonlyasfarasitconcernshealth.

Instancesofhealth-relatedseriousharmsaresevereillnesses.Ihavealreadysaidthat

noteverydiseaseequalsanimpairmentoftheabilitytoliveadecentlife.Butotherwise

whatkindsofdiseasesconstituteseriousharmsmightdifferbetweenpersons:Afarmer,

forinstance,mightdeemhayfevertobeaseriousimpairment,sincehisabilitytowork

inhisbusinessisimpairedbythiscondition,whereasothersmightnotbemuchaffected

intheirabilitytoliveadecentlife.Incontrasttothisvariabilityofnormative

assessment,ifsomeonehasanillnessthatinvolvesafundamentalthreattosurvival,an

impairmentofbasicabilities,orseverepainandagony,peoplewillimmediately

understandherclaimofneed(andtheyusuallybelieveittorequireanexplanation

whensomeoneinthissituationdoesnotclaimtobeinneed).Sothereseemstobea

differencebetweencaseslikethefarmerwithhayfeverandindisputablecasesofbasic

health-relatedneed.Whileinthelattercaseeveryonewouldagreethatthereisaneed

forrestorationofhealth,oratleastforthebestpossiblecompensationofthe

impairment,thisdoesnotholdfortheformercase.

16

Thisanalysisshowsthatneedsarenotduetodesires,noteventoverystrongdesires.A

desireisintentional;aneedisnotintentional.Thatistosaythatthecontentofadesire

dependsonamentalactdirectedonanobject,whileaneeddependsonastateofthe

world.Ifaperson,forinstance,needssomethinginordertogetridofaterrible

headache,thenbothAspirinandIbuprofenwillworkasmeanstofulfiltheneed,evenif

thepersondoesnotevenknowthatbothsubstancesarepainkillersordesperately

wantstotakeAspirinbutnotIbuprofen.Sowhatsatisfiesaneedisindependentof

mentalattitudes,whereaswhatfulfilsadesireisnot.

Sufficientarianismabouthealth-relatedneedswouldprobablybeststartwithserious

diseasesthataffecteveryone.Butitshouldnotrestrictitsscopeinawaythatexcludes

thepossiblejustificationofindividualbasichealth-relatedneeds.Forthepurposesof

generalhealthcareitisthereforeplausibletoaimatprovidingforthetreatmentof

almostallpossiblediseases.Yetwhenitcomestopublichealthmeasures,whicharethe

focusofthisessay,thereneedtobefurtherconcerns:First,sincepublichealthdoesnot

dealdirectlywiththetreatmentofdiseasebutwithriskstobeaffectedbydisease,and

sinceitoperatesonapopulationlevel,sufficientarianismaboutpublichealthwould

furtherneedanassessmentoftheseverityofriskstocitizensgenerally.Itwould

probablycomeupwithalistof"bigkillers",suchasheartandlungdiseaseandcancer,

andthemostfrequentseverelydisablingconditions,suchasstrokesandheadinjuries.

Infact,theseareofcoursealreadysomeofthemaintargetsofpublichealth

interventions.Second,especiallybecausepublichealthaimsatcausesofcauses,it

requiresanassessmentofthebenefitsofloweringrisksinrelationtothepossibleharms

thatarenotrelatedtohealth,buttootherbasicneedsofhumanbeings,suchastheneed

ofpeopletobefreetodecideforthemselves,orhavingaccesstopleasurablegoods.

Obviously,noteveryimprovementofhealthdispositionsisworththeeffort.Thisisnot

onlymeanteconomicallybutalso,moreimportantly,intermsofthecostsforcitizens'

abilitytoliveadecentlife.AsIhavestressedbefore,healthisnottheironlyconcern.

Itisoftensaidthatpublichealthinterventionscanavoidintrudingintopeople'slivesby

aimingatenablingconditionsinsteadofinterferingwiththeirchoices(Wilson2011).Up

toapointIwouldagreewiththisassessment.Indeed,forinstancethecapacitytomake

informedchoicesabouthealth-relatedbehaviourisimportanttoenablepeopletolive

accordingtotheirownconceptionofthegoodlife.Inaddition,certainmeansare

necessarytoliveadecentlife,andsocietyshouldbeheldresponsibleforitsprovision.

Yet,particularconditionsobviouslysteerchoices,ifonlybyrestrictingtheirscopeto

17

choicesthatareenabledbytheseveryconditions.Forinstance,ifaplaygroundisbuilt

onadesertedfieldinaneighbourhood,itmightbepossiblethatsomeolderchildren

nowcannotplayfootballanymoreandmightloseanaspectoftheirsociallife.Insome

sensethepotentialforhealthychoiceshasbeenimproved,butinotherrespectschoices

andtheconditionsofagoodlifehavebeenrestricted.Enablingpeopleinonerespect

mightgoalongwithhinderingtheminotherrespects.HenceIbelievepublic

interventionsalwayshavetobediscussedinabroadercontext,notsimplyasamatterof

enablementinacertainrespectsuchashealth.

Sufficientarianisminpublichealthshouldthereforebemodestinitsaims,andonly

promotetheprovisionofnecessarymeansforgeneralhealth-relatedbasicneeds.

Obviouslythereisalotofscopefordisagreementaboutwhatthisminimumrequiresin

termsofactualpublicprovisions.Suchdisagreementismostlyapoliticalissuethat

cannotbedecidedbyphilosophicalanalysis.Sufficientarianisminpublichealthshould

alsoalwaysconsiderotherbasicneedsofpeopleandhowtheymightbeaffectedby

publichealthpolicies.Thisagainrequiresbalancingofdifferentpossiblepoliciesanda

publicdebateabouttherelativeimportanceofvaluessuchashealth,security,and

individualliberty.Again,thereislittlephilosophy,oratheoryofjustice,alonecan

contributetosuchaquestion.Mygoalinthispaperhasthereforebeentoshowthe

normativebenefitsofsufficientarianisminpublichealth,especiallyinrestrictingstate

actiontotheprovisionofenablingconditionssothatcitizenscanavoidsevererisks

concerningbasichealth-relatedneeds,andalsotoanalysethecurrencyinwhichsucha

sufficientariantheorycanbefleshedout.InrespecttothelattertaskIhavemerelybeen

abletoofferinitialthoughtsregardingtheconceptofhealth-relatedbasicneeds.Amore

thoroughanalysiswouldrequiremuchmoredetail,andalsoacomparisontorecently

populartheories,suchasthecapabilitiesapproach(Venkatapuram2011;Ram-Tiktin

2012)ortheperspectiveof"habilitation"(Becker2012).

Itshouldbeemphasisedagainthatsufficientarianismisaversionofatheoryofjustice;

itisconcernedwithwhatweowetoeachother.Citizensmightdecide,inpolitical

processes,thattheywouldliketogranteachothermorethanjusttheminimal

requirementsofjustice.Thiswouldbeapoliticaldecisionmadebyapoliticalsovereign.

Myargumentwasonlytoclaimthatsocietiesthatdonotfulfiltheminimum

requirementofprovidingthenecessarymeansforinclusionofallcitizensfailon

normativegrounds.Myreasoningdoesnotexcludeprovisionsthat,forinstance,aimat

greaterhealthequalityoranimprovementofthehealthofthecitizenryoverandabove

18

theavoidanceofsignificantdisease.Yet,suchfurtherprovisionsarenotimperativeon

groundsofnormativetheory.

Conclusion

Ihavearguedinfavourofsufficientarianisminpublichealth.Sufficientarianism

providesanimportantbenefitinrestrictingtheaimsofstateaction,asitendorsesa

minimalconceptionofjustice.Invirtueofsettingsuchlimitstostateactionitisa

minimalisttheoryofcivilandhumanrights.Anexpansionofsuchrightsmightbe

achievedinrealpoliticalprocesses,butIdonotbelievethatanexpansivescopeof

individualrights,forinstancetothebestpossiblehealth-promotinglivingconditions,

canbejustifiedbynormativetheory.

Sufficientarianismisespeciallyhelpfulinrespecttopublicmeasuresaimedathealth

promotion.Publichealthpoliciesaredifficulttoassessintermsoftheiroutcomesand

success.Theyarealsonotoriouslycontestedinmanysocietiesintermsoftheirimpact

onpeople'slivesandchoices,evenwheretheseareallegedlyenablingcitizenstolivea

decentlife.Publichealthinterventionsshouldnotonlyberestrictedinscopeand

intensityforreasonsofsufficiencyperse,butalsobecausehealthoughttobeseenas

partofawidercontextofwelfareprovisioninliberalsocieties.Otheraspectsofwelfare

provisionmightcompromisethelegitimacyofhealthpolicies.

Asafinalcaveat,itshouldbeadmittedthatIhavealmostexclusivelydevelopedmy

argumentagainstthebackdropofseeinghealthasofintrinsicvalue,i.e.asavoiding

harm.Atthesametime,Ihavesaidthathealthcanalsobeseenfromaninstrumental

perspectiveasameanstopursueothergoodthingsinlife.Ifweseesocietyasasiteof

competition,whichinmanycountries,uptoapoint,isafittingdescription,wemight

needtoconsideraspectsofcomparativejustice,bothinrelationtotraditionalhealth

careandpublichealth.Here,theplausibilityofsufficientarianismmightcometoanend.

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DFG Research Group 2104

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