Regulation of the Global Marketplace for the Sake of Health

Mounting evidence suggests that socioeconomic status is a determinant of health. As nations around the globe increasingly rely on market-based economies, the corporate sector has come to have a powerful influence on the socioeconomic gradient in most nations and hence upon the health status of their populations. At the same time, it has become more difficult for any one nation to influence corporate activities, given the increasing ease with which corporations relocate their operations from country to country. As a result of all of these factors, nations wishing to assure the health of their populations will need to both involve the corporate sector and cooperate with other nations.In this article, we review the business ethics literature and consider what justification it might provide for requiring multinational corporations to attend to concerns about population health. We adopt Thomas Donaldson and Thomas Dunfee's Integrative Social Contracts Theory and Donaldson's ethics of international business to provide a basis for arguing that norms derived from a hypothetical social contract impose some ethical obligations on corporations. We modify their theories to suggest the possibility that emerging recognition of the relationship of economic gradient to health status may provide both new grounds for a duty of corporations to avoid depriving health, as well as a mechanism for having groups of nations as the parties to the contract with the corporation. This ethical analysis justifies the regulation of corporations that operate in the global marketplace and lends grounds for a global economy that aims to promote not only free trade, but population health as well.To be healthy is an interest of all individuals and it is an interest that individuals cannot address entirely on their own. The usual strategies for maintaining health have been found in the domains of public health and medical care. But those with a commitment to assuring population health will have to contend with a surprising finding -- one that defies the usual strategies of these traditional domains: A growing body of scientific evidence indicates that socioeconomic factors are powerful determinants of health. Specifically, both economic status and socioeconomic gradient influence health status, a circumstance that is true even when health care is universally available.This finding emerges at a time when a growing fraction of national economies lay in the hands of corporations that function beyond national borders. If multinational enterprises comprise a large fraction of most national economies, then any expectations we have of nations to attend to the economic determinants of health may ignore the reality that national governments cannot dictate entirely the way the distribution of income and wealth affects the health of their residents.The finding about the effects of socioeconomic status and income inequality thus catches us offguard for at least two reasons. First, it implies that the economic sector has a very significant role to play in assuring health, despite the fact that we have not generally expected or demanded of the economic sector that it function in a manner that serves this goal. Second, it suggests that, in order to ensure that corporations do play a role in assuring health, nations will need to work together, even though the need to meet the health requirements of the public has traditionally been seen as an obligation that each country owes only to its own citizens.It is the following question, then, that we wish to address in this paper: Are there moral grounds for requiring multinational corporations to attend to the concern that economic arrangements have a substantial impact upon population health? We argue that there are, and we locate *668 these grounds in an obligation of the corporation not to deprive individuals of health. Since perpetuation or exacerbation of income inequality does deprive people of health, we conclude that corporations have an obligation to forebear from aggravating, or even perpetuating, existing inequalities in wealth. We suggest, as well, that this obligation can and will be enforced if nations work together to constrain the activities of multinational corporations.Our reasoning is organized in five parts. First, we present evidence that socioeconomic status and income gradients are indeed strong determinants of health. Second, we argue that the global shift to market-based economies involving multinational entities diminishes the capacity of national governments to assure the health of their populations on their own. Instead, they will need the international cooperation and participation of multinational enterprises to address the interplay between socioeconomic gradient and health. Third, we identify ethical arguments derived from the business ethics literature, particularly Integrative Social Contracts Theory, as a potential basis for justifying an expectation one might impose on multinational enterprises. Fourth, we extend Integrative Social Contracts Theory to specifically justify requiring these enterprises to avoid depriving the public of health. Finally, we conclude that our argument provides justification for international agreements requiring multinational enterprises to bear responsibility both directly and indirectly for population health, and we allude to the policy implications of these arguments.