![Sample our Politics & International Relations journals, sign in here to start your FREE access for 14 days]({"type":"image" , "src" : "/sda/5947/TOC-Subject-Sample-2021-Politics-International-Relations.jpg"})
Abstract
Medicines exist to treat a great number of illnesses, but they can be costly and unaffordable. This article analyses the obligations of states to provide medicines originating from International Covenant on Economic, Social and Cultural Rights (ICESCR) article 12 on the right to health, which arguably stipulates a right to medicines. Given the limited resources available, it is asked which medicines states shall provide and prioritise. The article then asks whether the provision of medicines by states ought to be guided by the right to health. In order to answer this question, multidisciplinary perspectives including health policy, bioethics and socio-legal studies are considered. The article concludes that the ICESCR right to health and medicines entails legal, moral and political flaws. The indeterminacy of the duties corresponding to the right and its penchant for public health and the collective dimension are found to be particularly problematic. Thereby the article proposes to contribute to critical perspectives on human rights, with a particular emphasis on economic, social and cultural rights.
Acknowledgments
This article is based on my PhD thesis, titled ‘The Human Right to Medicines in Sub-Saharan Africa’ (University of Westminster, 2010). I am thankful to Dr Brigit Toebes and Richard Earle for having read drafts of my article and having provided insightful and thorough comments. I am also thankful to Dr Brigit Toebes and to Dr Myriam Feinberg for their work and support in relation to the editing of this publication.
Disclosure statement
No potential conflict of interest was reported by the author.
Notes on contributor
Laura Niada is working as Learning Adviser and Visiting Lecturer at the University of Westminster, London. She researches in the areas of international law, human rights, the third world and development.
Notes
1 The term ‘medicine’ is used as a synonym of ‘drug’. The term ‘medicine’ is often being replaced in the public health literature as the term drug can denote an ‘illicit drug’.
2 World Health Organization, The World Medicines Situation (Geneva: World Health Organization, 2004), 62.
3 World Health Organization, World Health Report 2003 (Geneva: World Health Organization, 2003), 120.
4 National Health Service, NHS Constitution for England (United Kingdom: Department of Health, 2013), arts 1 and 2.
5 Michael D. Rawlins and Anthony Culyer, ‘National Institute for Clinical Excellence and its Value Judgments', British Medical Journal 329, no. 7459 (2004): 224; Sarah Boseley, ‘Drugs Watchdog Condemns Roche for High Price of Breast Cancer Therapy’, The Guardian, 8 August 2014, http://www.theguardian.com/society/2014/aug/08/drugs-watchdog-nice-roche-breast-cancer-nhs-limit (accessed 21 August 2014); Press Association, ‘Nice Decision on Prostate Cancer Drug is a “Kick in the Teeth” for Patients', The Guardian, 15 August 2014, http://www.theguardian.com/society/2014/aug/15/nice-prostate-cancer-drug-abiraterone (accessed 21 August 2014).
6 Access to medicines is defined as having essential medicines continuously available and affordable at public or private health facilities or drug outlets that are within a one hour walk of the population. See United Nations Development Group, Indicators for Monitoring the Millennium Development Goals (New York: United Nations, 2003). Accordingly, access to medicines entails two main components: availability and affordability. Availability implies the physical presence of medicines, while affordability relates to the individuals' resources to acquire medicines.
7 Committee on Economic, Social and Cultural Rights (CESCR), General Comment 14: The Right to the Highest Attainable Standard of Health, UN Doc. E/C.12/1999/5, 2000, para. 47.
8 Office of the High Commissioner for Human Rights (OHCHR), ‘Status of Ratification Interactive Dashboard’, http://indicators.ohchr.org/ (accessed 28 September 2014).
9 For other sources of the right to medicines such as the African Charter on Human and Peoples' Rights, and other human rights, such as the right not to be subjected to torture, inhuman and degrading treatment, or the right to life, and customary international law, see Laura Niada, ‘The Human Right to Medicines in Relation to Patents in Sub-Saharan Africa: Some Critical Remarks', The International Journal of Human Rights 15, no. 5 (2011): 700–727.
10 Sigrun I. Skogly and Mark Gibney, ‘Transnational Human Rights Obligations', Human Rights Quarterly 24 (2002): 791. A few considerations may justify such authority. The committee is a body of independent experts which was established under ECOSOC Resolution 17 (1985) to carry out the monitoring functions assigned to the United Nations Economic and Social Council (ECOSOC) in Part IV of the ICESCR. See OHCHR, ‘Committee on Economic, Social and Cultural Rights – Sessions', 2008, http://www2.ohchr.org/english/bodies/cescr/sessions.htm. The committee has been active in elaborating General Comments on various ICESCR provisions and on how to better implement the covenant; issuing reporting guidelines for the ICESCR parties, relating to issues and policies on which states have to focus their attention; analysing states' implementation of the covenant and expressing ‘concluding considerations' on them. Laura Niada, ‘Hunger and International Law: The Far-Reaching Scope of the Right to Food’, Connecticut Journal of International Law 22, no. 1 (2006): 149.
11 International Covenant on Economic, Social and Cultural Rights (ICESCR), UN Doc. A/6316 (1966), entered into force 23 March 1976, article 12.
12 ICESCR article 12(2)(d) (my emphasis).
13 Ibid., article 2(1).
14 CESCR, General Comment 14, paras 33–6.
15 Ibid., para. 33.
16 Ibid., para. 34.
17 Ibid., para. 35.
18 Ibid., para. 36.
19 CESCR, General Comment 14, para. 17. On the equivalence between the terms medicines and drugs see note 1.
20 Ibid., para. 53.
21 The CESCR recommends remedies for the violation of the right to health in non-mandatory terms. Ibid., para. 59.
22 ICESCR article 2(1).
23 See Philip Alston and Gerard Quinn, ‘The Nature and Scope of States Parties Obligations Under the International Covenant on Economic, Social and Cultural Rights', Human Rights Quarterly 9, no. 2 (1987): 156–229.
24 Committee on Economic, Social and Cultural Rights (CESCR), General Comment 3: The Nature of State Parties Obligations, United Nations Economic and Social Council, UN Doc. E/1991/23, annex III at 86, 1991, para. 9.
25 United Nations, UN Doc. E/CN.4/SR.271, 1952, 5.
26 Alston and Quinn, ‘States Parties Obligations', 180. On the identification of the ICESCR maximum available resources and a discussion on the taxation necessary to realise economic, social and cultural rights see also Diane Elson, Radhika Balakrishnan, and James Heintz, ‘Public Finance, Maximum Available Resources and Human Rights', in Human Rights and Public Finance: Budgets and the Promotion of Economic and Social Rights, ed. Aoife Nolan, Rory O'Connell, and Colin Harvey (Oxford: Hart Publishing, 2013), 13–40. On progressive realisation, maximum available resources and minimum core see also Rory O'Connell and others ‘A Human Rights Framework Part 1: Exploring Article 2(1) ICESCR Obligations', in Applying An International Human Rights Framework to State Budget Allocations: Rights and Resources, ed. Rory O'Connell and others (London: Routledge, 2014), 61–86.
27 ICESCR article 12(1).
28 Brigit Toebes, The Right to Health as a Human Right in International Law (Oxford: Intersentia/Hart, 1999), 45–6; Holger P. Hestermeyer, ‘Access to Medication as a Human Right’, Max Planck Yearbook of United Nations Law 8 (2004): 127.
29 CESCR, General Comment 14, para. 9.
30 ICESCR article 12(2).
31 Ibid., para. 10.
32 Ibid.
33 CESCR, General Comment 14, para. 43(d) and 47.
34 CESCR, General Comment 14, 47. O'Connell and others define minimum core obligations as the ‘bottom or floor from which states should endeavor to go up’. O'Connell and others, International Human Rights Framework, 80.
35 The former Special Rapporteur makes clear that ‘the right to health encompasses access to non-essential and essential medicines. While a State is required to progressively realise access to non-essential medicines, it has a core obligation of immediate effect to make essential medicines available and accessible throughout its jurisdiction.' Paul Hunt, ‘Report to the General Assembly (Maternal Mortality and Access to Medicines)’, UNDoc.A/61/338, 2006, para. 58. See also para. 38.
36 CESCR, General Comment 14, para. 33.
37 In the Viceconte case the Argentinean Federal Court of Appeals also referred to the ICESCR in order to appreciate the social right to health and to assert the state obligation to manufacture the hemorrhagic fever vaccine as requested by the plaintiffs. See Argentina, Federal Administrative Court of Appeals, 1998, Viceconte, Mariela c. Estado Nacional (Ministerio de Salud y Ministerio de Economía de la Nación) s/ Acción de Amparo, 2 June 1998 para. 5.
38 See Hunt, ‘Report to the General Assembly (Maternal Mortality and Access to Medicines)’
, para. 40. Paul Hunt served as UN Special Rapporteur on the Right to Health from 2002 to 2008.
39 Hestermeyer, ‘Access to Medication as a Human Right', 125; Alicia E. Yamin, ‘Not Just a Tragedy: Access to Medications as a Right under International Law’, Boston University International Law Journal 21, no. 2 (2003): 325–371.
40 World Health Organization, World Health Report 2000 (Geneva: World Health Organization, 2000), 95.
41 United Nations, UN Doc. E/CN.4/SR.271, 5.
42 CESCR, General Comment 3, para. 10.
43 Roughly, primary care is the first point of consultation, secondary care is specialist and tertiary care is specialised on referral.
44 WHO, Public Health, http://www.who.int/trade/glossary/story076/en/ (accessed 21 September 2014). See also Brigit Toebes, ‘Human Rights and Public Health: An Unsettled Relationship', International Journal of Human Rights 19, no. 4 (2015): this issue (Special Issue: ‘Human Rights and Public Health’, ed. Brigit Toebes and Laura Niada). The American Public Health Association has synthesised the many definitions and perspectives on public health and identified six basic principles of contemporary public health theory and practice (APHA): (a) emphasis on collective responsibility for health and the prime role of the state in protecting and promoting the public's health; (b) focus on whole populations; (c) emphasis on prevention, especially the population strategy for primary prevention; (d) concern for the underlying socio-economic determinants of health and disease, as well as the more proximal risk factors; (e) multidisciplinary basis which incorporates quantitative and qualitative methods as appropriate; and (f) partnership with the populations served. World Bank, Public Health and World Bank Operations (Washington, DC: International Bank for Reconstruction and Development/World Bank, 2002), 5.
45 ICESCR article 12(2)(a), (b) and (c). See also Toebes, noting within this special issue that ‘WHO's public health campaigns…may embrace issues like vaccination and control of infectious diseases, motor-vehicle safety, occupational health, safe drinking water, maternal and child health, coronary heart disease and stroke, and prevention of smoking’. Toebes, ‘Human Rights and Public Health’, X.
46 CESCR, General Comment 14, paras 19, 43, note omitted.
47 World Bank, Public Health and World Bank Operations, 5
48 Again, primary health care is not a clear concept, as also recognised by the CESCR. CESCR, General Comment 14, endnote 9. As the WHO acknowledges in its World Health Report 2000, the implementation of primary health care has been problematic, also because its meaning is in fact ambiguous. WHO, World Health Report 2000, 13.
49 Katrina Tomasevski, ‘Health Rights', in Economic, Social and Cultural Rights: A Textbook, ed. Asbjørn Eide, Catarina Krause, and Rosas Allan (The Hague: Kluwer Law International, 1995), 125 (italics in original).
50 Toebes, Right to Health, 8–14; Hestermeyer, ‘Access to Medication as a Human Right', 111; Toebes, ‘Human Rights and Public Health’, X. [on Chadwick etc.]
51 ICESCR article 12(2)(d).
52 ICESCR article 12(2)(c).
53 ICESCR article 12(1). See above section 2.1.
54 CESCR, General Comment 14, paras 4, 8; Toebes, Right to Health, 51–2. See also Tomasevski, ‘Health Rights', 125.
55 CESCR, General Comment 14, para. 59, footnote 30.
56 CESCR, General Comment 14, para. 19, note omitted.
57 See also Laura Niada, ‘The Human Right to Medicines in Sub-Saharan Africa’ (PhD dissertation, University of Westminster, 2010), 161–4.
58 CESCR, General Comment 3, para. 12.
59 Niada, ‘The Human Right to Medicines', 161–4.
60 CESCR, General Comment 3, para. 10; CESCR, General Comment 14, 43, 47.
61 On the relationship between the concept of progressive realisation and the concept of minimum core obligation see Amrei Muller, The Relationship between Economic, Social and Cultural Rights and International Humanitarian Law: An Analysis of Health-Related Issues in Non-International Armed Conflicts (Leiden: Martinus Nijhoff Publishers, 2013), 85. (Muller argues that a minimum core obligation is compatible with the concept of progressive realisation enshrined in article 2(1) ICESCR as the ‘obligation to progressively realise ESC rights is hardly thinkable without a domestic minimum standard to start from’.)
62 CESCR, General Comment 14, para. 43(d) and note 5.
63 WHO, ‘The Selection and Use of Essential Medicines', Technical Report Series 920, no. 54 (2003): 55.
64 WHO, How to Develop and Implement a National Drug Policy (Geneva: WHO, 2000), 7.
65 WHO and Health Action International (HAI), Measuring Medicine Prices, Availability, Affordability and Price Components, 2nd ed. (WHO and HAI, 2008), 28, 34.
66 Ibid., 28.
67 WHO, ‘The Selection and Use of Essential Medicines', 54. On the use of this definition see Niada, ‘The Human Right to Medicines', 174.
68 Richard Laing and others, ‘25 years of the WHO Essential Medicines Lists: Progress and Challenges', Lancet 361 (May 17, 2003): 1725. Some anti-retrovirals, however, have been introduced in the most recent versions of the WHO EML, relaxing the requirements of cost-effectiveness. Ibid.
69 South African Standard Treatment Guidelines and Essential Drugs List for Primary Health Care 2003. See also Mickey Chopra and others, ‘“Nothing New”: Responses to the Introduction of Antiretroviral Drugs in South Africa’, AIDS 20, no. 15 (2006): 1975–7. But see South African Standard Treatment Guidelines and Essential Drugs List Hospital Level Adults 2012.
70 Love recalls that only 14 (12 on the core list and two on the complimentary list) of the total 312 medicines on the [2005] EDL are under a United States patent. James P. Love, ‘Letter Asking WHO Review of the Essential Drugs List (EDL) as it Relates to Patented Products', 2006, http://www.cptech.org/blogs/ipdisputesinmedicine/2006/12/letter-asking-who-review-of-essential.html. Reportedly, less than 5% of medicines on the WHO's essential drugs list are subject to patent protection. Roya Ghafele, Perceptions of Intellectual Property: A Review (London: Intellectual Property Institute, 2008), 16.
71 Love, ‘Letter’.
72 The Economist, ‘Worse than AIDS', 1 March 2014.
73 CESCR, General Comment 3, para. 10 (italics added).
74 Hogerzeil and colleagues for example have identified and analysed 71 completed court cases from 12 low-income and middle-income countries in which individuals or groups had claimed access to essential medicines with reference to the right to health in general, or to specific human rights treaties ratified by the government. They found that in 59 cases access to essential medicines as part of the fulfilment of the right to health could indeed be enforced through the courts. Most cases came from Central and Latin America, with South Africa being the only African case identified. Hans V. Hogerzeil and others, ‘Is Access to Essential Medicines as Part of the Fulfilment of the Right to Health Enforceable through the Courts?’, Lancet 368 (July 22, 2006): 305.
75 For a discussion on the justiciability of economic, social and cultural rights see for example Michael Dennis and David Stewart: ‘Justiciability of Economic, Social, and Cultural Rights: Should There Be an International Complaints Mechanism to Adjudicate the Rights to Food, Water, Housing, and Health?’, American Journal of International Law 98 (2004): 462–515; Hestermeyer, ‘Access to Medication as a Human Right', 125; Alicia E. Yamin, ‘Not Just a Tragedy: Access to Medications as a Right under International Law’, Boston University International Law Journal 21, no. 2 (2003).
76 In the Soobramoney case the South African Constitutional Court permitted the individual enforcement of access to treatment, but the claim was based on access to emergency medical treatment rather than health care. South Africa, Constitutional Court, 1997, Soobramoney v. Minister of Health (KwaZulu-Natal), Case No. CCT 32/97, 27 November 1997. See also Joan Fitzpatrick and Ron C. Slye, ‘Republic of South Africa v. Grootbroom, Case No. CCT 11/00. 2000 (11) BCLR 1169. Constitutional Court of South Africa, 4 October 2000. Minister of Health v. Treatment Action Campaign. Case No. CCT 8/02′, American Journal of International Law 97 no. 3 (2003): 678.
77 For a background of the case see ESCR-Net, ‘Minister of Health v Treatment Action Campaign (TAC)’, http://www.escr-net.org/docs/i/403050 (accessed 9 October 2014).
78 South Africa, Constitutional Court, 2002, Minister of Health v. Treatment Action Campaign [TAC], Case No. CCT 8/02, 5 SA 721 (CC), 5 July 2002, paras 5, 25. South Africa, Constitution of the Republic of South Africa, Act No. 108 of 1996, articles 27(1), 28(1).
79 Minister of Health v. TAC, paras 32, 37. On the reasonableness of the intervention see also ibid., para. 125.
80 Ibid., para. 35. It has to be noted that South Africa has not ratified the ICESCR. OHCHR, ‘Status of Ratification’. It has however signed the covenant and the court does refer to the treaty in its ruling. Ibid., Minister of Health v. TAC, paras 26–33.
81 Minister of Health v. TAC, para. 37.
82 Ibid., para. 34.
83 Ibid., para. 67.
84 Robert Beaglehole and Ruth Bonita, Public Health at the Crossroads: Achievements and Prospects (Cambridge: Cambridge University Press, 2004), 264–6; Joseph C. D'Oronzio, ‘Keeping Human Rights on the Bioethics Agenda’, Cambridge Quarterly of Healthcare Ethics 10, no. 3 (2001): 223–226; Tomasevski, ‘Health Rights', 125. For instance, vaccinations may be imposed that could have side-effects. O'Neill remarks that while (the new) medical ethics is centred on autonomy, it has ‘relatively little to say about public health, where interventions are often (and sometimes necessarily) compulsory’. Onora O'Neill, ‘Public Health or Clinical Ethics: Thinking beyond Borders', Ethics and International Affairs 16, no. 2 (2002): 36.
85 International Covenant on Civil and Political Rights (ICCPR) UN Doc. A/6316 (1966), entered into force 23 March 1976, article 12.
86 ICCPR article 19.
87 ICCPR article 21.
88 ICCPR article 22. See also Toebes, ‘Human Rights and Public Health’.
89 Toebes, Right to Health, 275.
90 This account draws liberally from Hammer and Berman, who identify three goals and principles of public health policy in developing countries: improving aggregate health status, relieving equity/poverty, and improving individual welfare. Jeffrey S. Hammer and Peter Berman, ‘Ends and Means in Public Health Policy in Developing Countries', Health Policy 32, nos 1–3 (1995): 29.
91 DALYs are defined as ‘a measure of the future stream of healthy life (years expected to be lived in full health) lost as a result of the incidence of specific diseases and injuries', i.e. a sum of ‘both premature mortality (years of life lost because of premature mortality or YLL) and disability (years of healthy life lost as a result of disability or YLD, weighted by the severity of the disability)’. International Bank for Reconstruction and Development (IBRD)/The World Bank, The Global Burden of Disease and Risk Factors (International Bank for Reconstruction and Development (IBRD)/The World Bank, 2006), 3. QALYs, i.e. quality-adjusted life-years, are the inverse form of DALYs. Ibid., 48.
92 Hammer and Berman, ‘Ends and Means', 31.
93 Commission on Macroeconomics and Health, Macroeconomics and Health: Investing in Health for Economic Development (Geneva: WHO, 2001); World Bank, World Development Report 1993: Investing in Health (New York: Oxford University Press, Publication 1993); WHO, Tough Choices: Investing in Health for Development: Experiences from National Follow-up to the Commission on Macroeconomics and Health (Geneva: WHO, 2006).
94 The report of the Commission on Macroeconomics and Health gives recommendations for the utilisation of resources domestically in developing countries and for the disbursement of foreign aid.
95 Commission on Macroeconomics and Health, Macroeconomics and Health, 12.
96 Ibid., 69.
97 John McKie and Jeff Richardson, ‘The Rule of Rescue’, Social Science and Medicine 56 (2003): 2407.
98 Ibid.; Tony Hope, John Reynolds, and Sian Griffiths, ‘Rationing Decisions: Integrating Cost-Effectiveness with Other Values', in Medicine and Social Justice: Essays on the Distribution of Health Care, ed. Rosamond Rhodes, Margaret P. Battin, and Anita Silvers (New York: Oxford University Press, 2002), 146.
99 McKie and Richardson, ‘The Rule of Rescue', 2407.
100 Hammer and Berman, ‘Ends and Means', 36.
101 Especially, if DALYs are considered. Hope, Reynolds, and Griffiths, ‘Rationing Decisions', 146.
102 Ibid.
103 Ibid.
104 Ibid.
105 Rod Sheaff, The Need for Healthcare (London: Routledge, 1996), 176.
106 Ibid., 169.
107 Kenyon J. Mason and Graeme T. Laurie, Mason and McCall Smith’s Law and Medical Ethics (Oxford: Oxford University Press, 2006), 428. The definition of need for medical care is taken from Anthony J. Culyer, Need and the National Health Service (Oxford: Martin Robertson, 1976).
108 In fact, collecting epidemiological data can be extremely impracticable in some circumstances: Niada, ‘The Human Right to Medicines', Chapter 2.
109 Rony Brauman, ‘Questioning Health and Human Rights', MSF Article, 2 April 2004. Brauman is a doctor at MSF. In this article, he refers, in particular, to humanitarian work in health care.
110 Mason and Laurie, Mason, 428. See also Nick Bosanquet, ‘A “Fair Innings” for Efficiency in Health Services', Journal of Medical Ethics 27 (2001): 228. DALYs and QALYs may also be utilised to estimate the benefits of a health intervention to individuals.
111 Hogerzeil and others, ‘Is Access to Essential Medicines'; Ole Frithjof Norheim and Bruce M. Wilson, ‘Health Rights Litigation and Access to Medicines: Priority Classification of Successful Cases from Costa Rica's Constitutional Chamber of the Supreme Court’, Health and Human Rights 2014 16, no. 2 (2014), http://www.hhrjournal.org/2014/10/02/health-rights-litigation-and-access-to-medicines-priority-classification-of-successful-cases-from-costa-ricas-constitutional-chamber-of-the-supreme-court/ (accessed 19 October 2014). See also Alicia Yamin and Siri Gloppen, eds, Litigating Health Rights: Can Courts Bring More Justice to Health? (Cambridge, MA: Harvard University Press, 2011).
112 Norheim and Wilson, ‘Health Rights Litigation’; Yamin and Gloppen, Litigating Health Rights.
113 Norheim and Wilson, ‘Health Rights Litigation’.
114 Dan W. Brock, ‘Priority to the Worse Off in Health-Care Resource Prioritization’, in Medicine and Social Justice: Essays on the Distribution of Health Care, ed. Rosamond Rhodes, Margaret P. Battin, and Anita Silvers (New York: Oxford University Press, 2002), 362–372.
115 Hammer and Berman, ‘Ends and Means', 34.
116 Ibid., 31.
117 Ibid.
118 The theoretical framework of this article is inspired by different contributions including: the critical approaches to law and human rights of Arendt, Douzinas and Luhmann; the critique of ‘modernity’ by Bauman and Luhmann; Luhmann's social systems theory; the critique of positivism and quantification in science and public life of Marcuse and Porter; public health and medical ethics. Hannah Arendt, The Human Condition (Chicago: University of Chicago Press, 1958); Hannah Arendt, The Origins of Totalitarianism (London: Andre Deutsch, 1986); Costas Douzinas, The End of Human Rights (Oxford: Hart, 2000); Niklas Luhmann, Law as Social System (Oxford: Oxford University Press, 2004); Niklas Luhmann, I Diritti Fondamentali come Istituzione (Bari: Edizioni Dedalo, 2002/1965); Zygmunt Bauman, Modernity and the Holocaust (Ithaca, NY: Cornell University Press, 1993); Niklas Luhmann, Social Systems (Stanford, CA: Stanford University Press, 1995); Niklas Luhmann, Observations on Modernity, trans. William Whobrey, eds Timothy Lenoir and Hans U. Gumbrecht (Stanford, CA: Stanford University Press, 1998); Herbert Marcuse, One-Dimensional Man (London: Routledge, 2002[1964]); Theodore M. Porter, Trust in Numbers: The Pursuit of Objectivity in Science and Public Life (Princeton NJ: Princeton University Press, 1995); Lilani Kumaranayake and Damian Walker, ‘Cost-Effectiveness Analysis and Priority-Setting: Global Approach Without Meaning?’, in Health Policy in a Globalising World, ed. Kelley Lee, Kent Buse, and Suzanne Fustukian (Cambridge: Cambridge University Press, 2002), 140–156; Vicente Navarro, ‘Assessment of the World Health Report 2000’, Lancet 356 (2000), 1598–1601; Vicente Navarro, ‘Can Health Care Systems Be Compared Using a Single Measure of Performance?’, American Journal of Public Health 92, no. 1 (2002), 31–34; Sheaff, Need for Healthcare.
119 Luhmann, Law as Social System; Luhmann, I Diritti Fondamentali.
120 Giorgio Agamben, Homo Sacer. Sovereign Power and Bare Life, trans. Daniel Heller-Roazen (Stanford, CA: Stanford University Press, 1998); Michel Foucault, L'Histoire de la Sexualite, I, La Volonté de Savoir (Paris: Gallimard, 1976). See also Didier Fassin, ‘Entre Politiques du Vivant et Politiques de la Vie: Pour une Anthropologie de la Santé’, Anthropologie et Sociétés 24, no. 1 (2000); Didier Fassin, ‘Humanitarianism as a Politics of Life', Public Culture 19, no. 3 (2007): 499–520; Mariella Pandolfi, ‘L'Industrie Humanitaire; Une Souveraineté Mouvante et Supracoloniale: Réflexion sur l'Expérience des Balkans', Multitudes 3 (2001): 97–105; Mariella Pandolfi, ‘“Moral Entrepreneurs”, Souverainetés Mouvantes et Barbelés', Anthropologie et Sociétés 26, no. 1 (2002): 29–51; Mariella Pandolfi, ‘Contract of Mutual (In)Difference: Governance and the Humanitarian Apparatus in Contemporary Albania and Kosovo’, Indian Journal of Global Legal Studies 10 (2003): 369–381.
121 Niklas Luhmann, Die Gesellschaft der Gesellschaft (Frankfurt am Main: Suhrkamp, 1997), 992–3.
122 Niklas Luhmann, ‘Are There Still Indispensable Norms in our Society?’, Soziale Systeme 14, no. 1 (2008): 28, 29 (Special Issue: ‘“Tragic Choices”: Luhmann on Law and States of Exception’, ed. William Rasch).
123 Luhmann, Law as Social System, 483.
124 Luhmann, Die Gesellschaft, 1022, translated in Hans-Georg Moeller, ‘Human Rights Fundamentalism', Soziale Systeme 14, no. 1 (2008): 139 (special issue ‘“Tragic Choices”: Luhmann on Law and States of Exception’, ed. William Rasch).
125 Ibid.
126 Luhmann, ‘Indispensable Norms', 19.
127 Ibid., 414.
128 Niklas Luhmann, ‘Das Paradox der Menschenrechte und drei Formen seiner Entfaltung', in Soziologische Aufklärung (Opladen: Westdt, Verlag, 1995), 231, trans. in Moeller, ‘Human Rights Fundamentalism’, 131.
129 On Luhmann's use of the term communication see Luhmann, Social Systems, 59.
130 Luhmann, I Diritti Fondamentali.
131 Agamben, Homo Sacer, 127.
132 Michel Foucault, Dits et Ecrits, 1976–1988, Vol. 2 (Paris: Gallimard, 2001), 818.
133 Foucault, L'Histoire, 138.
134 Ibid., 136.
135 Michel Foucault, Security, Territory, Population (Lectures at the College De France) (Basingstoke: Palgrave Macmillan, 2007).
136 Foucault, Dits et Ecrits, 818; Foucault, Security.
137 Foucault, Security. In this context, security can be seen as both an end of biopower and a means of biopower to perpetuate itself.
138 Ibid., 74.
139 Ibid., 57.
140 Ibid., 63.
141 See section 3.1.
142 Minister of Health v. TAC, paras 32, 37.
143 On the relationship between human rights, group rights, and people's rights see Peter Jones, ‘Human Rights, Group Rights, and People's Rights', Human Rights Quarterly 21 (1999): 80–107. On the use of collective complaints in relation to the right to health see also Toebes, ‘Human Rights and Public Health’.
144 Toebes, Right to Health.
145 Luhmann, Die Gesellschaft, 992–3.
146 CESCR, General Comment 14, para. 19 (note omitted).
147 See also CESCR, General Comment 14, para. 53.
148 Luhmann, Law as Social System, 418. See also ibid., 151, 165.
149 Tomasevski, ‘Health Rights', 125.
150 Foucault, Security.
151 Andreas Philippopoulos-Mihalopoulos, Niklas Luhmann: Law, Justice, Society (Oxon: Routledge-Cavendish, 2010), 157.
152 Similarly, Hope and others conclude that since each theory for allocation of health resources faces difficulties, it is more important to concentrate on the procedure to reach the decisions. See Hope, Reynolds, and Griffiths, ‘Rationing Decisions', 144.