How should morality play a role in global health?

SUMMARY BOX

• Moral determinants of health are generally discussed in the context of individual and public health but not in global health.

• Moral clarity is the integration of internal ethical guidance, formal ethical directives and organisational accountability even in the face of pressure or uncertainty.

• Indigenous cultures may provide contextually relevant systems that strengthen trust, inclusivity and collective responsibility in implementing global health initiatives.

• We propose a practice-oriented integration of morality in global health curriculum.

Introduction

Global health is an interdisciplinary field focused on the improvement of health equity and outcomes across the world’s populations, addressing transnational health challenges through cooperative international action. Differing from traditional medicine or public health, global health gives precedence to cross-frontier collaboration, strengthening of the health system and reduction of global health disparities.

In this commentary, we argue that moral clarity must be reasserted as a central pillar of global health practice. Integrating morality into decision-making is foundational to addressing inequities and ensuring inclusivity. By blending operational excellence with ethical clarity, defined here as the deliberate and consistent application of ethical reasoning, human rights and inclusiveness, global health can move beyond just addressing gaps; it can build systems rooted in fairness, compassion and shared humanity. The suggested pyramid (figure 1) delineates the hierarchical framework through which morality informs global health practices.

Figure 1. Suggested pyramid delineates the hierarchical framework through which morality informs global health practices. At the foundational level, institutional requirement represents the necessary legal, regulatory and organisational infrastructure that supports global health initiatives. Building on this base, diversity, equality and equity emerge as essential principles, underscoring the need to address health disparities and ensure that marginalised and vulnerable populations receive adequate attention and care. The next level, ethical framework, provides ethical guidelines that direct global health decisions, emphasising justice, fairness and accountability. Health and human rights illustrates the intrinsic link between access to health care and fundamental human rights. Universal health coverage follows as a core pillar of global health advocating for the provision of health services without financial barriers. Utilitarianism reflects the application of the greatest good for the greatest number. This moral philosophy is frequently used in health resource allocation, where decisions are made to maximise overall well-being, particularly in resource-constrained settings. At the apex is moral clarity and framework, which synthesises all the principles into a cohesive, overarching moral approach to global health.

Immanuel Kant, one of the most influential philosophers, laid the foundation for defining morality. Kant argued that morality is rooted in the concept of duty, guided by reason, and governed by the categorical imperative, a universal principle that requires individuals to act in ways that could become a universal law. According to Kant, morality transcends subjective preferences and emotions, relying instead on rationality to determine the ethical correctness of actions.¹

The theme of our commentary is to reassert the centrality of morality in global health, which is often dominated by technocratic approaches, social media and distrust.

Moral determinants of global health

Moral determinants of health are extensively discussed in the context of individual and public health but have received less attention in global health and humanitarianism. Berwick highlighted the critical role of morality in shaping health outcomes and emphasised the need for a more robust ethical framework in addressing systemic inequities. Berwick argued that moral determinants such as fairness, justice and compassion are foundational to achieving health equity but are often overlooked in health policy contexts, where operational and technical priorities tend to dominate decision-making.²

Morality in global health refers to the application of ethical principles and values such as justice, equity and compassion to guide decision-making and actions in health initiatives that impact diverse populations across the world. It involves addressing disparities, ensuring equitable access to healthcare and upholding the dignity and rights of individuals while navigating cultural, social and economic complexities.

Though often used interchangeably, moral determinants differ from social or structural determinants. Social and structural determinants are external factors, including poverty, education, housing and structural injustices, which shape health outcomes. Moral determinants, on the other hand, look at ethical choices, incentives and systems of values that guide the way decisions are made, priorities are set and policies are enforced within those structural environments.

Ethical opinions of such issues vary along the continuum: on one end is moral absolutism, the viewing of some actions as always right or always wrong; on the other is moral relativism, the belief that ethical assessments are situationally and culturally determined. Between these is moral objectivity, an effort to establish universal ethics but also an awareness of variation across cultures. Synthesising these perspectives is needed to develop ethically grounded interventions and policies that resonate with global health objectives while also honouring the diverse values of the populations they aim to benefit.

While the ideal of global health emphasises health equity and population well-being, suggesting a moral agenda, this ideal often remains more aspirational than actionable. It is reasonable to expect that a curriculum in global health would give due prominence to morality; human rights; ethics; and diversity, equity and inclusion (DEI). However, these principles are not always taught with the emphasis they merit. Foundational documents such as the ‘United Nations Charter’ and the ‘Red Cross Code of Conduct’ lay out a clear moral imperative to promote and protect health for all, grounded in humanitarian principles of impartiality, neutrality and human dignity.

Successes of moral clarity in global health

 Universal recognition of the moral obligation to eliminate a deadly disease led to coordinated global efforts. Smallpox became the first disease eradicated, saving millions of lives. Access to antiretroviral therapy for equitable access to life-saving treatments for HIV/AIDS patients in low-income countries highlighted the moral imperative to address global health inequities. The WHO’s ‘3 by 5’ initiative successfully delivered antiretroviral therapy to millions by 2005.³ COVID-19 vaccine distribution (COVAX Initiative, 2021) founded on the principle of equitable vaccine distribution, emphasised moral responsibility towards low-income countries.

Misses due to lack of moral clarity in global health

While global health has seen notable successes, there have also been moral failures that cannot, and should not be ignored. The delayed international response to the Ebola outbreak highlighted a failure to prioritise vulnerable populations, resulting in over 11 000 deaths.⁴ Similarly, vaccine hoarding during COVID-19 saw high-income countries prioritised their own populations, leaving low-income nations waiting for vaccines for prolonged periods. The Tuskegee Syphilis Study is a stark reminder of ethical violations, where treatment was withheld from African American participants, eroding trust in public health institutions.⁵

Moral clarity in humanitarian missions

Moral clarity in humanitarian missions refers to the ability to clearly define, understand and act on ethical principles in complex and often chaotic situations. It involves navigating moral dilemmas with integrity, prioritising human dignity, justice and compassion while balancing competing priorities like resource allocation, cultural differences and political pressures. Moral clarity is the integration of internal ethical guidance, formal ethical directives and organisational accountability all leading to such a place where decisions are grounded in justice, compassion and transparency, even in the face of pressure or uncertainty.

 A key aspect is prioritising dignity, ensuring that every individual is treated with respect and compassion, irrespective of their circumstances.⁶ It also provides a framework for navigating ethical dilemmas, enabling organisations to make principled choices when faced with competing interests or limited resources. Furthermore, moral clarity requires actively addressing injustice rather than remaining neutral, as neutrality can inadvertently perpetuate harm or inequity. Finally, it emphasises accountability, ensuring that humanitarian efforts are transparent, fair and aligned with the ethical principles they claim to uphold.⁷

 Global health can take a cue from indigenous moral philosophies such as Africa’s Ubuntu, which places emphasis on community health, care for each other and shared responsibility through the ethic of ‘I am because we are’. In contrast with Western individualistic ethics, Ubuntu fosters health campaigns that uphold collective dignity and interdependence.⁸ In West Africa, during the Ebola outbreak, traditional healers and local leaders were capable of interpreting public health messages into locally relevant practices, demonstrating the strength of context-driven approaches. Similarly, the Aravind Eye Care System (Home - Aravind Eye Care System Aravind Eye Care System) in India has become a global model for delivering high-quality, low-cost eye care to millions, using an innovative, self-sustaining model that leverages community outreach, standardised processes and a focus on affordability. This approach, rooted in the values of compassion, has not only restored vision to millions but also set a benchmark for sustainable healthcare systems worldwide.

Drawing from the author’s humanitarian work in the Republic of Guyana, South America, it is evident that specialised surgeries like kidney and cornea transplants have significantly improved life span and quality of life. In this context, an American philanthropist, driven by a deep sense of responsibility towards his country of birth, the Republic of Guyana, initiated a humanitarian mission. This effort, while not primarily motivated by ethical or moral considerations, aimed to address critical healthcare gaps. However, the US team involved approached the mission through a lens of compassion and ethical clarity, establishing guidelines to ensure fair and inclusive conduct.⁹ In the densely populated slums of a metropolitan city in a low- and middle-income country, unmet surgical needs are frequently unaddressed despite the existence of universal healthcare. Recognising this gap, a collaborative team from the USA and India developed a programme (Surgical Accredited Trained Healthcare Initiative) to train community health workers which enabled them to educate slum residents about available healthcare services. This initiative, which reached a cohort of approximately 70 000 people, resulted in a significant improvement in the conversion rate from unmet to met surgical needs. While the project was initially driven by a response to glaring healthcare disparities, its implementation remained firmly grounded in ethical principles, ensuring inclusivity and equal access regardless of race or religion.¹⁰

 Moral obligations should be distinguished from the work of humanitarians which is generally motivated by benevolence,empathy, or the desire to improve the lives of strangers and reduce suffering. However, these are not codified and obligatory. In the public mind, kindness and compassion, sincerely wanting to share and improve the lives of strangers, are synonymous with morality; however, morality should have special connotation in global health.

 Moral clarity fosters accountability among humanitarian actors by clearly defining ethical standards and responsibilities.

Building trust and credibility: clear moral stances enhance the credibility of humanitarian organisations, fostering trust among affected populations and donors.

Effective resource allocation: with moral clarity, resources are allocated to maximise impact while maintaining fairness, reducing wastage or favouritism.

Mitigating ethical drift: moral clarity prevents ‘ethical drift’, where organisations compromise ethical principles under external pressures like funding or politics.

Encouraging cultural sensitivity: moral clarity ensures respect for cultural values while upholding universal human rights, avoiding imposition of foreign norms.

Guiding long-term impact: beyond immediate relief, moral clarity drives sustainable solutions that empower affected communities and build resilience.

Teaching morality in global health

Teaching morality in global health is essential for fostering ethical decision-making and equitable practices among practitioners and policymakers. The global health landscape is marked by complex dilemmas, such as resource allocation, cultural diversity and systemic inequities. A robust curriculum on morality can prepare professionals to address these challenges with integrity.

Several global initiatives already highlight the importance of ethics education in public health. The WHO, for instance, offers ethics and human rights training modules for health policy and practice. Global bioethics training programmes are funded by the Fogarty International Center at the NIH, with a focus on low- and middle-income countries. Our perspective supports the more even, practice-oriented integration of morality in global health education that extends beyond theory to decision-making, leadership and cultural competence.

 A comprehensive curriculum on morality in global health should include both theoretical and practical components. Courses should cover ethical frameworks, such as utilitarianism, deontology and principlism, with real-world case studies on issues like pandemic responses, humanitarian crises and health disparities. Role-playing simulations can immerse students in scenarios requiring ethical choices, such as allocating scarce resources in disaster-stricken regions.

 There are several well-documented incidences in which Red Cross, OXFAM and Doctors Without Borders were hit by scandals,^{11 12} which were later perceived to be a failure of leadership in practising morality and principles of decolonisation.¹³ Donors and international agencies can be moral and ethical by cultivating a culture of accountability and transparency.

Comparative analysis of moral frameworks in global health

Global health relies on various moral frameworks to address ethical dilemmas, allocate resources and guide decision-making. These frameworks—utilitarianism, deontology, virtue ethics, communitarianism and principlism—offer distinct approaches, each with strengths and limitations (table 1). A deeper understanding of these frameworks can help practitioners design more equitable and effective interventions.¹⁴

Table 1. Comparative analysis of moral frameworks in global health.

Moral framework	Key principle	Strengths	Limitations	Application in global health
Utilitarianism	Maximise overall well-being; the greatest good for the greatest number	Promotes efficiency and scalability; useful in cost-effectiveness analysis	Can neglect marginalised individuals; may overlook justice for minorities	Resource allocation in pandemics, vaccination strategies
Deontology	Duty-based ethics; follow moral rules regardless of outcome	Protects individual rights; ensures non-discrimination	Can be rigid; may ignore broader societal impact	Ethical standards in clinical trials and universal access
Virtue ethics	Emphasises moral character and intention (eg, empathy, compassion)	Encourages personal responsibility; useful in ambiguous moral situations	Subjective; varies across cultures	Humanitarian work, frontline healthcare ethics
Communitarianism	Focus on community values and collective good	Promotes cultural sensitivity and trust	May conflict with individual autonomy or global standards	Localised public health interventions, traditional medicine integration
Principlism	Balances autonomy, beneficence, non-maleficence and justice	Adaptable to diverse scenarios; practical in complex cases	Competing principles can create ethical dilemmas	Vaccine trials, patient care decisions in emergencies

No need

Utilitarianism emphasises maximising overall well-being by implementing actions that provide the greatest benefit to the largest number of people. This framework is widely used in global health for cost-effectiveness analysis, particularly in resource allocation during crises. Its strength lies in promoting efficiency and scalability; however, it often neglects marginalised groups, focusing on aggregate outcomes over individual rights.

Deontology focuses on adherence to moral rules or duties, emphasising the inherent value of individual rights regardless of outcomes. This framework ensures justice and non-discrimination in healthcare, making it essential in areas like clinical trials and access to treatment. For instance, ethical guidelines in trials uphold equal treatment for participants, irrespective of economic considerations. While deontology safeguards individual autonomy, it can lead to rigid decisions that may not account for the broader societal impact, such as prioritising lifesaving treatments based solely on duty rather than resource availability.

Virtue ethics highlights the moral character of individuals, advocating for virtues like empathy, compassion and integrity in global health practices. This framework is particularly relevant in humanitarian missions, where healthcare workers often face morally complex situations requiring personal judgement. Virtue ethics strengthens personal accountability and ethical behaviour but can be subjective, as cultural differences influence perceptions of virtues.

Communitarianism prioritises the values and well-being of the community over individual interests, making it effective in designing culturally sensitive health programmes. This approach builds trust by aligning interventions with local customs and traditions.

Principlism integrates four key ethical principles—autonomy, beneficence, non-maleficence and justice—into decision-making processes. It is particularly flexible, allowing for diverse ethical considerations in complex scenarios. For example, principlism is commonly applied in vaccine trials, where researchers must balance participant safety with societal benefits. Its strength lies in adaptability; however, competing principles can create dilemmas, such as prioritising justice over autonomy in scenarios where limited resources must be distributed equitably.

Digital ethics

Emerging technologies like AI and social media have promise in global health but generally progress beyond ethical control. This has parallels with earlier problems where technical solutions dominated over ethical problems. For instance, artificial intelligence (AI) bias can be harmful for marginalised communities, and disinformation degrades public trust in institutions.¹⁵ Recommendations on AI in health place a strong focus on transparency, accountability and equity, values important for ethical digital innovation for global health.¹⁵ An algorithmic bias in AI-driven healthcare systems can disproportionately harm vulnerable populations, such as diagnostic technologies that risk undercounting minority groups.

Policy implications

Undue reliance on outcome measurement can also reflect moral gaps, emphasising quantitative metrics like vaccination rates while overlooking long-term trust and behavioural change. This narrow focus risks masking failures and unintended consequences. Additionally, careerism may well have superseded altruism in global health, which has eroded trust and given rise to cynicism within practitioners of global health and the population they serve. Global health teaching and practice may be better focused on what is moral—from teaching to research, policy, donor and organisational practice and working on the ground with local partners and beneficiaries.

Global health often struggles to align ethical aspirations with practical realities. Funding tends to prioritise the politically influential while tropical diseases tend to be neglected. Power imbalances are a constant challenge, with Global North experts often dominating decision-making, side-lining local voices and underpaying frontline workers. Partnerships with dubious unethical corporations further undermine credibility, suggesting a tolerance for compromising values.¹⁶ A notable example is India’s successful polio eradication campaign, declared polio-free by the WHO on 27 March 2014. Yet caution is warranted; India is a vast country, and in extreme rural or hard-to-reach areas, the possibility of isolated cases being missed by health professionals remains a concern. This underscores the importance of sustained surveillance and vigilance even after official eradication milestones are achieved.

Similarly, the development and mass use of oral rehydration therapy in Bangladesh stand as a powerful example of how localised, culturally sensitive solutions can have a transformative impact on global health, reducing child mortality from diarrhoeal diseases by millions. These examples highlight the importance of integrating ethical clarity and cultural context in public health interventions, ensuring that rapid, one-size-fits-all approaches, seen in COVID-19 and HIV/AIDS campaigns, do not overlook the diverse needs and values of affected populations.

Conclusions

 Morality should be a compass for global health, informing decisions that respect justice and human dignity, especially for marginalised groups. And yet, whereas ethical concerns are frequently paramount in domestic health policy, global health efforts far too often privilege operational objectives above moral principles—widening existing inequalities. To transcend this paradigm, curriculum in global health must instil ethical reasoning at its foundation, creating professionals who balance technical skill with a firm commitment to social responsibility. Established moral systems like utilitarianism and human rights-based methods furnish valuable tools to address recalcitrant ethical dilemmas and establish accountability.

As technology such as AI, data analysis, big data analytics and social media redefines global health, it must be regulated through an ethical framework to counter disinformation, uphold individual rights and ensure transparency. Their confluence has to be undergirded by a robust ethical framework that safeguards truth, human dignity and transparency. Ethical principles for AI must move beyond regulation to empowerment. This entails cultivating critical digital literacy whereby communities can recognise misinformation, question technological decisions and participate in co-deciding how innovation shapes the common good.¹⁷ Public health authorities must also develop digital literacy, so they can rationally evaluate health information and determine technology’s role in contributing to global health.

As the world faces complex health challenges, moral considerations ensure that vulnerable populations receive the attention they deserve. Through this commentary, we recognise the power of moral clarity in driving equitable, just and impactful solutions.

Data availability statement

No data are available.