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. 2026 Jun 16;13:e150. doi: 10.1017/gmh.2026.10255

The moral economy of worth: Why rights-based mental health must engage cultural logics of contribution

Yasuhiro Kotera 1,2,3,✉
PMCID: PMC13373263  PMID: 42466253

Abstract

Global mental health advances its commitment to rights-based care grounded in dignity, autonomy and freedom from coercion, assuming worth is inherent and support is a right. This Perspective aims to strengthen that agenda by adding a cultural-implementation lens: in many settings, everyday moral reasoning links worth to contribution (e.g., labour, perseverance and fulfilment of social obligations), creating a moral economy of worth in which legitimacy is earned, relational and conditional. Drawing on cross-cultural psychology, the article argues that contribution-based moralities are especially salient where three cultural dimensions co-occur: restraint, collectivism and long-term orientation. In such contexts, support can be morally misread as unearned reward, rest as indulgence and reduced functioning as moral failure, producing ethical dissonance that shapes help-seeking, clinical practice and policy uptake without implying rejection of human rights. Using Japan as an illustrative case, the article shows how norms of perseverance (ganbaru) and regulated dependence (amae) can intensify contingent self-worth, self-stigma, rapid-return expectations and family hesitation to seek support. To improve legitimacy and sustainability, five strategies are proposed: broaden what counts as contribution; frame recovery as stewardship for future participation; avoid morally triggering eligibility language; use culturally credible lived-experience narratives; and engage institutions across levels that shape moral judgement.

Keywords: rights-based care, moral economy, contribution, collectivism, long-term orientation

Impact statement

This article offers a practical way to strengthen rights-based mental health reform by introducing a cultural-implementation lens: the “moral economy of worth.” It explains that, in many settings, people judge legitimacy and deservingness through everyday expectations of contribution, such as working, persevering, fulfilling roles and not burdening others. Where these norms are strong (often in cultures characterised by restraint, collectivism and long-term orientation), rights-based messages such as “support is a right” can be morally misread as “unearned reward,” and rest or reduced functioning can be interpreted as irresponsibility. The article synthesises these dynamics and provides five actionable strategies to make rights-based care morally legible: broaden what counts as contribution (including caregiving and self-management), frame recovery as responsible stewardship for future participation, design eligibility language that avoids moral “red flags,” use culturally credible lived-experience narratives to renegotiate norms, and engage institutions across levels (families, workplaces, welfare systems and media) that shape moral judgement.

This matters because expanding services and legal protections alone may not increase uptake if people fear shame, loss of standing or being seen as “not contributing.” By addressing the moral meaning of support, rights-based reform can reduce stigma-driven avoidance, improve engagement and become more sustainable across diverse cultural contexts.

Beneficiaries include people experiencing mental health difficulties and their families (through lower shame and easier help-seeking), clinicians and service leaders (through improved communication and engagement) and policymakers and implementers (through better-designed programmes that achieve inclusion and participation without unintentionally activating stigma).

Global mental health has entered a period of renewed commitment to rights-based care, driven by international frameworks that foreground dignity, autonomy, legal protection and freedom from coercion (Puras and Gooding, 2019; World Health Organization, 2021; Mahdanian et al., 2023). In practice, a rights-based approach in mental health prioritises non-discriminatory access, person-centred and recovery-oriented support in the community, continuity of care and safeguards against coercion and degrading treatment, with service quality judged not only by clinical outcomes but also by dignity, participation and autonomy (World Health Organization, 2021; United Nations, 2022). These initiatives, from the WHO’s guidance on community-based mental health services to the UN’s Convention on the Rights of Persons with Disabilities (United Nations, 2022), share a core ethical assumption: human worth is inherent, not earned. Support, in this vision, is not a reward for merit but a right of all people as human beings. Operationally, this aims to reduce inequalities by ensuring access and continuity are based on need and rights, not perceived deservingness. This Perspective is intended to strengthen the rights-based agenda by identifying a cultural-implementation lens that can improve legitimacy, uptake and sustainability across settings. At the same time, international human rights frameworks have also been critiqued as culturally situated, reflecting particular moral and political traditions (Mutua, 2008; Summerfield, 2012). This strengthens our argument: the dissonance described here can be understood as tension between competing cultural frameworks, reinforcing the need for cultural engagement in implementation.

Yet across many cultural contexts, including but not limited to East Asia, moral understandings of worth do not begin from unconditional dignity. Instead, deeply rooted cultural logics define a person’s value through contribution, especially through labour, perseverance and fulfilling social obligations (Gobel and Miyamoto, 2023). For example, Confucianism defines personhood and moral worth through the fulfilment of social roles, diligent effort and contribution to the collective (Chen, 2023). Confucian ethics stress that personhood is achieved by enacting virtues, such as perseverance, diligence and self-cultivation, within social relationships and roles (Yuan et al., 2023). These expectations form a moral economy of worth: drawing on “moral economy” as an established analytical concept for the normative rules and moral evaluations that organise distributions of recourses and recognition (Thompson, 1971; Fassin, 2009). Here, it refers to a widely shared cultural belief that resources, respect and even moral standing should be distributed in proportion to one’s contribution to family, community or society. Such systems are not simply attitudes: they are moral grammars that organise social life, identity and interpersonal obligations.

This moral economy is captured succinctly in the Japanese proverb “働かざる者食うべからず (Those who do not work shall not eat).” Although often invoked in contemporary Japan, similar notions appear across cultures shaped by Confucian (Chan, 2011), Protestant (Weber, 2001), socialist (van Oorschot, 2000) and even familial duty-based ethics (Doi, 2002). These ideas do not represent resistance to human rights per se. Rather, they represent a different moral ontology of what it means to deserve support, one in which worth is conditional, relational and earned. Global mental health has largely overlooked these cultural moral systems. While global mental health frameworks increasingly emphasise rights-based, person-centred care (e.g., WHO guidance on community mental health services and QualityRights), they rarely make explicit how culturally patterned moral logics of deservingness, such as contribution-based worth, can shape the perceived legitimacy of support and thereby influence uptake and implementation (World Health Organization, 2021, 2025; United Nations, 2022). This article focuses on that under-addressed dimension. As a result, rights-based approaches may confront silent but powerful friction: not necessarily because communities reject rights, but because alternative moral frameworks can shape how value, responsibility and entitlement are understood.

Cultural configurations behind contribution-based worth

Why do some societies maintain strong contribution-based moralities, while others more readily accept unconditional support as a right? Insights from cross-cultural psychology offer a useful analytical lens (Kirmayer, 2025). Drawing on cross-cultural psychology, this article uses a hypothesis-generating heuristic. Contribution-based worth may be especially salient where three cultural tendencies co-occur: Restraint, Collectivism and Long-term orientation (Hofstede et al., 2010). This triad is presented as a proposition to guide future empirical testing rather than as a settled empirical model, informed by cross-cultural theory and by observed convergences in settings where contribution-based moralities appear salient (e.g., Japan). Hofstede’s national cultural dimensions have been widely used but also extensively critiqued, including concerns about within-country heterogeneity, temporal change and reifying “national culture” (McSweeney, 2002). These dimensions can be used as a pragmatic heuristic to characterise broad cultural tendencies relevant to the argument, not as precise or deterministic measures of individuals or societies.

Restraint (versus indulgence)

In high-restraint cultures, such as Japan, South Korea, China, Germany and Romania, people are socialised to prioritise duty over personal desire, self-control over pleasure and moral discipline over self-expression (Hofstede et al., 2010). In such contexts, benefits not earned through effort may be perceived as indulgent, morally questionable or socially destabilising (Felix et al., 2002; Dumbravå, 2017; Chen et al., 2024; Takamatsu et al., 2024). The idea that one could receive support independent of contribution conflicts with a deeply embodied ethic of self-denial and moral discipline. This moral backdrop reinforces the belief that worth must be demonstrated through effort.

Collectivism (versus individualism)

Collectivist societies emphasise interconnectedness, role fulfilment and obligations to family and community (Hofstede et al., 2010). A person’s value is not purely individual but relational: one “earns” worth by fulfilling expected roles. Someone unable to contribute due to illness, disability or unemployment may be perceived (and may perceive themselves) as a burden (Fan et al., 2023). In these cultural logics, receiving support without contribution violates the relational ethic that binds groups together. Collectivist logics can also motivate strong obligations to care for vulnerable in-group members. The argument here is therefore not that collectivism universally reduces care, but that where worth is tightly linked to contribution, people may still receive support even as the experience heightened shame and self-stigma, and may delay help-seeking or seek care only when impairment becomes undeniable. In such contexts, the friction may operate more through the conditions and meanings of care (e.g., moralised dependence and pressure for rapid return) than through outright absence of care. Rights-based approaches, which emphasise individual entitlements independent of social roles, thus encounter conceptual resistance.

Long-term orientation (versus short-term orientation)

Long-term oriented cultures value perseverance, future-oriented sacrifice and sustained commitment to collective goals (Hofstede et al., 2010). This dimension strengthens expectations of industriousness and social responsibility (Halkos and Skouloudis, 2017; Beugelsdijk and Welzel, 2018). Idleness is not merely impractical; it is morally suspect. In such contexts, “taking time off” for mental health may be viewed not as rest, but as moral failure or irresponsibility (Kotera et al., 2022).

Countries where these three dimensions overlap, such as Japan, China, South Korea, Taiwan, Singapore, Hong Kong, parts of India and certain European societies with strong duty ethics (e.g., Germany and Romania), tend to maintain powerful contribution-based moralities. In these contexts, moral worth is strongly indexed to doing one’s part: reliably fulfilling relational and institutional obligations, exercising self-control over personal desire and sustaining long-term commitments to family, organisation and society (Miller and Bersoff, 1992; Beugelsdijk and Welzel, 2018).

Japan as an illustrative, not exceptional, case

Japan exemplifies the triadic configuration of restraint, collectivism and long-term orientation. The ethic of ganbaru (頑張る; a moralised norm of persevering and “pushing through” despite difficulty) and the ambivalent social evaluation of amae (甘え; culturally recognisable dependence on others’ indulgence, acceptable in some close relationships but often criticised in public as immature or burdensome) can reinforce conditional worth, where esteem is closely tied to meeting duties and maintaining self-control (Mattig, 2013). Mental health challenges often lead to profound self-stigma, as individuals feel they have failed in their social obligations (Kotera et al., 2023a; 2023b). Workplace policies may formally allow leave, but cultural expectations encourage rapid return, even when clinically harmful (Kotera et al., 2022). Families may hesitate to seek support out of concern that doing so signals inadequate contribution to group harmony (Kotera et al., 2023a, 2023b). None of these dynamics stems from the rejection of human rights. Rather, they reflect a moral economy where value is tied to fulfilling expected roles and demonstrating effort.

Analogous “earned worth” logics can emerge in societies shaped by different moral traditions (e.g., Confucian, Protestant, socialist or strong family duty norms). However, these logics are not culturally identical: they differ in the specific virtues emphasised (e.g., harmony vs. individual responsibility), the social arenas where judgement is applied (family, workplace and state) and how stigma and deservingness are expressed. The point is, therefore, not that the phenomenon is universal, but that similar forms of contribution-based deservingness can take distinct cultural shapes, supporting the need for culturally engaged implementation.

The clash with rights-based mental health

Table 1 summarises common points of ethical dissonance: how rights-based principles may be interpreted within contribution-based moral economies. These contrasts are not incompatibilities in principle; they highlight where the moral meaning of support, rest and entitlement can diverge and thereby shape help-seeking and implementation.

Table 1.

Where rights-based reforms can be morally misread in contribution-based contexts

Table 1. long description.

Rights-based principles/values Contrasts within contribution-based moral economies (potential moral misreadings)
Worth is unconditional Worth is earned through social and economic contribution
Support is a right, not a reward Support is legitimate only when a contribution has been demonstrated
Rest and recovery do not diminish one’s value Rest may be interpreted as indulgence or irresponsibility
Autonomy and dignity persist regardless of functional capacity Non-contribution generates moral judgement and shame
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Thus, rights-based frameworks do not simply introduce new services: they introduce new moral expectations. When they enter cultural contexts where worth is contribution-based, they may be experienced as ethically dissonant. People may avoid seeking help not because they reject rights, but because they fear violating cultural norms about what makes a person worthy (Yang et al., 2014). In this account, the moral economy of worth is not a “barrier” separate from stigma, but part of the cultural substrate that shapes what stigma is about locally. Where worth is tightly coupled to contribution and self-discipline, mental distress (especially when not visibly embodied) can be moralised as insufficient effort or failure of responsibility, generating public stigma and self-stigma (Link and Phelan, 2001; Corrigan and Watson, 2002; Kotera et al., 2023a; 2023b). Stigma is therefore treated here as the more proximal mechanism linking moral economies to help-seeking, engagement and implementation. Mental health practitioners may feel tension between professional values and community moralities (Kleinman and Benson, 2006; Hatzenbuehler, 2016). Policymakers may frame support programmes in ways that inadvertently activate stigma.

This is not a marginal issue. In global mental health, culturally grounded moral economies are often treated as “barriers” to be removed, rather than as coherent systems of meaning that organise shame, responsibility and help-seeking. When reforms overlook these moral logics, they may misread reluctance as resistance, design services that feel morally risky to use and inadvertently intensify stigma, thereby undermining uptake and impact. Of course, implementation of rights-based services is also constrained by non-cultural barriers, such as resource and workforce limitations, infrastructure gaps, organisational resistance and political will, so the cultural lens proposed here should be understood as complementary rather than exhaustive.

Integrating moral economies into rights-based mental health

A culturally viable rights-based approach does not treat contribution-based moralities as simply “wrong” or to be replaced. Instead, it engages them as moral grammars that organise legitimacy and shame, and it seeks to reduce the moral risk attached to help-seeking while keeping rights-based commitments explicit.

“Working with” an existing moral economy does not mean leaving it unchanged; it means expanding and reinterpreting it from within (e.g., broadening what counts as contribution) rather than replacing it with an external moral vocabulary. A key risk of this approach is that it could be misread as endorsing conditional deservingness – that is, that people must prove worth to merit care. The strategies below are therefore framed as implementation supports, not as new eligibility criteria, and they retain the normative claim that dignity and access to care are unconditional.

Broaden what counts as a contribution

In contribution-based moralities, worth is tied to usefulness and responsibility. Rights-based services gain legitimacy when societies recognise that contribution is not only paid labour. Caregiving, community participation, relational maintenance and self-management (e.g., sleep, treatment adherence and relapse prevention) (Merlo and Fagundes, 2025) can be positioned as socially valuable work, often essential for group stability.

Example: Services can explicitly recognise “contribution” as self-management and relational work (e.g., attending appointments, practising sleep routines, relapse prevention, caregiving), and reflect this in care plans and recovery reviews.

Reframe rest and recovery as duty-consistent

Rest is vulnerable to being interpreted as indulgence (Kotera, 2021). Reframe it as responsible stewardship of one’s functional capacity: recovery is not withdrawal from duty, but maintenance and restoration of the ability to contribute. This framing resonates especially in long-term oriented contexts, where short-term sacrifice is acceptable when it protects future obligations.

Example: Sick-leave letters and clinician conversations can frame rest as “stewardship of future participation” (e.g., “taking time now helps you return safely and reduces burden on family/work later”).

Design policy language and eligibility rules to avoid moral “red flags”

Some terms and criteria inadvertently activate suspicions of undeserved reward (e.g., language that frames support as discretionary “help” or “approval,” or that defines eligibility primarily through incapacity and deficit labels rather than participation and inclusion). Rights-based guidance already points in this direction by recommending accessible, non-technical language and permitting non-medical/culturally meaningful descriptions of distress (e.g., “emotional distress” and “unusual experiences”), rather than relying on narrow clinical labels (World Health Organization, 2025). In the same spirit, national guidance has explicitly avoided traditional terms such as “serious mental illness” to respect multiple understandings of distress (NHS England, 2025).

This extends existing rights-based guidance by highlighting that, in contribution-based moral economies, welfare-eligibility language can be heard as indulgence or unearned reward even when the intent is rights protection. Practically, eligibility rules can therefore be framed around maintaining inclusion and participation (consistent with CRPD Article 19’s emphasis on community living and participation) rather than around deficit formulations (“because you cannot”) (United Nations, 2006). For example, the same eligibility decision can be communicated in two ways: Deficit framing: “Support is available because your condition prevents you from working or fulfilling expected roles.” Participation framing: “Support is available to help you remain included and participate in community, family, and work life, with adjustments as needed.”

Example: Phrasing that emphasises incapacity (“because you cannot…”) can inadvertently cue shame and “undeservedness,” whereas participation-oriented phrasing can reduce moral threat.

Use culturally credible narratives to renegotiate norms

Abstract rights language often fails to shift moral intuitions. Lived-experience accounts, especially from respected in-group members, can model a new moral interpretation (Braddock and Dillard, 2016): seeking help is responsible, prevents burden on others and protects relationships (Thornicroft et al., 2016). Narratives can also separate “rest” from “selfishness,” and “support” from “moral failure.” (Slade et al., 2024).

Example: Short peer narratives can model “help-seeking as responsible” (e.g., “getting support early helped me keep my commitments to my family/work”).

Engage institutions that shape moral judgement

Moral economies are produced and reinforced through everyday institutions (families, workplaces, schools and faith/community organisations), but they are also shaped by wider structures, including welfare regimes, labour markets, media/NGOs and transnational norms, which can stabilise or contest local expectations of worth and responsibility (Wheeler, 2019). Importantly, these moral economies are not only “cultural”; they are also sustained by political-economic conditions. Labour-market insecurity, welfare conditionality and productivity-oriented norms (amplified through economic globalisation) can intensify the coupling of worth with paid work and measurable contribution, even within the same national culture. A cultural-implementation lens can complement political-economy analysis by showing how structural pressures are interpreted through locally salient moral logics in everyday life and services. Sustainable change requires multilevel moral dialogue: co-developing messaging with community institutions, training supervisors and frontline staff and aligning programme design with participation-oriented goals so that help-seeking is legitimised while valued commitments to responsibility and harmony are preserved.

Example: Partner with employers/schools/faith groups to co-produce messages that legitimise help-seeking as responsible maintenance, and train supervisors to avoid “effort-blame” framing.

Conclusion

Human dignity may be universal, but the cultural foundations of who is perceived as deserving support are not. Moral economies of worth (shaped by restraint, collectivism and long-term orientation) profoundly influence how rights-based mental health reforms are understood and accepted. If global mental health is to be truly global, it must expand its conceptual frameworks to include these cultural moralities, not merely as contextual barriers but as central determinants of meaning, legitimacy and care.

Integrating rights-based approaches with moral economies of contribution does not weaken human rights. It has the potential to strengthen their cultural resonance, ethical grounding and practical viability. Only by engaging these moral systems can rights-based mental health become sustainable and globally meaningful.

Acknowledgements

None.

Long descriptions

Table 1. Long description

The table consists of two columns and four rows of comparative data.

* Row 1: Rights-based principle states worth is unconditional. The contribution-based contrast is that worth is earned through social and economic contribution.

* Row 2: Rights-based principle states support is a right, not a reward. The contribution-based contrast is that support is legitimate only when a contribution has been demonstrated.

* Row 3: Rights-based principle states rest and recovery do not diminish one’s value. The contribution-based contrast is that rest may be interpreted as indulgence or irresponsibility.

* Row 4: Rights-based principle states autonomy and dignity persist regardless of functional capacity. The contribution-based contrast is that non-contribution generates moral judgement and shame.

Navigate back to Table 1..

Open peer review

To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2026.10255.

Data availability statement

This study did not involve the novel creation, generation, or analysis of primary research materials. All relevant literature is cited in the References.

Author contribution

Conceptualisation, Investigation, Project administration, Validation, Writing – original draft preparation, Writing – review and editing: Y.K.

Financial support

No funding was used for this work.

Competing interests

The author declares none.

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Glob Ment Health (Camb). doi: 10.1017/gmh.2026.10255.pr2

Review: The moral economy of worth: Why rights-based mental health must engage cultural logics of contribution — R0/PR2

Laurence Kirmayer 1

This is a clear, well-written and useful paper. I have only to minor suggestions:

(1) Both the ganbaru and amae value systems are presented without much explication. Amae, in particular, has been described as something tolerated and accepted, so a few words about the nature of the ambivalence around it would be useful.

(2) There fact that there are many ethical systems that emphasize “earned worth” (Confucian, Protestant, socialist, etc.) suggests that universal human rights are not simply at odds with specific cultural values but represent an intervention to assert a set of values or ideals that aim to have a transformative effect on culture. Is there a risk that by operating within the moral economy of having to prove one’s worth to obtain care, we undermine this call for change?

Glob Ment Health (Camb). doi: 10.1017/gmh.2026.10255.pr3

Review: The moral economy of worth: Why rights-based mental health must engage cultural logics of contribution — R0/PR3

Anonymous

I. General Assessment

Thank you for the opportunity to review this manuscript. This Perspective addresses a genuine and important topic: the gap between the universalistic values underlying rights-based mental health approaches and the culturally embedded moral logics that can shape understanding of worth, deservingness, and support. The central thesis, that contribution-based moralities could create ethical dissonance undermining the uptake of rights-based reforms, is plausible and policy-relevant. The paper has real potential to contribute to the global mental health literature.

Several strengths deserve to be acknowledged. The paper is grounded in a rich and well-selected literature, drawing productively across cross-cultural psychology, mental health policy, and implementation research. The introduction is clear and well situated in the international context, and the rhetorical positioning of the paper as strengthening rather than challenging the rights-based agenda is sound. The section on cultural configurations is clearly written and succeeds in illustrating how cultural dimensions can account for variation in social representations of individual worth. The Japanese case is effectively used to demonstrate how these dynamics translate into concrete health behaviours and clinical experience. The clash section is useful and concrete in mapping tensions between rights-based principles and contribution-based moral economies. Finally, the strategies section provides the paper’s clearest policy value, and the core framing, working with existing moral economies rather than against them, is a conceptually original and practically promising contribution.

Nonetheless, major revisions are required to address issues affecting the argumentative coherence, epistemological positioning, and practical operationalisation of the article. Cross-cutting remarks are first described, followed by section-specific comments.

II. Cross-Cutting Remarks

Comment n°1: Across the manuscript are several cases where it is not clearly differentiated whether the author refers to empirical findings, theoretical propositions, or speculative arguments. Several claims that are advanced as established facts are better characterised as plausible hypotheses. Representative examples are discussed in the section-by-section comments below (comments n°8, 9, 12, 16, 22), but the authors are invited to review the entire manuscript to further clarify the distinction between what is known, what is proposed and what is conjectured.

Comment n°2: The concept of “moral economy” is central to the entire argument but is neither defined nor anchored in the literature. Is it borrowed as an established analytical concept, or used metaphorically? This ambiguity weakens the theoretical foundation of the paper and should be resolved at the outset. Clarifying this will improve the understanding of the proposed “moral economy of worth”.

Comment n°3: An important angle is not addressed in the article: to what extent is the formulation of fundamental human rights itself shaped by a Western system of values (e.g., Mutua, 2002)? If the framework that is being promoted globally is already culturally situated, the dissonance described in this paper is not simply a clash between universal rights and local moralities, but between competing cultural frameworks. This debate exists in the critical global mental health literature (e.g., Summerfield, 2012) and deserves acknowledgement. It would actually strengthen the paper’s argument for cultural engagement.

Mutua, M. (2002). Human rights: A political and cultural critique. University of Pennsylvania Press.

Summerfield D. Afterword: Against “global mental health”. Transcultural Psychiatry. 2012;49(3-4):519-530. doi:10.1177/1363461512454701

Comment n°4: The paper consistently frames contribution-based moralities as cultural phenomena, but does not engage with the structural and economic conditions that produce and sustain them. The role of capitalist ideology and economic globalisation in shaping the perception that individual worth is tied to productive contribution is a significant omission. Presenting contribution-based worth as an essentially cultural characteristic, without acknowledging its entanglement with global economic structures, risks essentialising what is also a product of political economy. The authors are invited to acknowledge this dimension, even briefly, and to consider whether it strengthens rather than undermines their case for cultural engagement.

Comment n°5: Across the paper, the authors frame contribution-based cultural logics as barriers to rights-based approaches implementation. A question arises regarding the level of analysis at which the argument operates: the mechanism through which they interpret the effects of these cultural logics on help-seeking and clinical experience is, consistently, stigma and self-stigma. Could they rather be describing a culturally specific dimension of stigma centred on social worth and perceived contribution? If this reading is correct, cultural moral economies may be better understood as the substrate that gives stigma its specific local content, rather than as a primary barrier in themselves, with stigma remaining the more proximal mechanism linking cultural context to health behaviour. The authors are invited to reflect on this distinction and to clarify the relationship between moral economy and stigma as levels of analysis. Engaging more explicitly with the stigma literature could considerably strengthen the paper’s theoretical contribution.

III. Section-by-Section Comments

1. Introduction

Comment n°6: The rights-based approach is introduced without sufficient contextualisation. What does this framework concretely entail for mental health care (e.g., in terms of access, continuity, quality of services)? Spelling this out would help readers immediately grasp what is at stake when cultural moral logics create friction with this approach.

Comment n°7: Relatedly, the authors should clarify what the ethical assumption of inherent human worth is operationally supposed to produce in mental health systems (e.g., reducing inequalities in care access). Without this, the downstream consequences of cultural misalignment remain abstract.

Comment n°8: Line 106 authors write: “Global mental health has largely overlooked these cultural moral systems”. This claim is the argumentative pivot of the entire paper, yet it is asserted without citation or exemplification. This is the point that most needs to be substantiated: which specific frameworks, policy documents, or dominant approaches are being characterised here, and on what evidence?

Comment n°9: Lines 106–109, authors write: “As a result, rights-based approaches often confront silent but powerful friction: not because communities reject rights, but because they operate within alternative moral frameworks that structure the meaning of value, responsibility, and entitlement. ». This is presented as an established fact, but is rather a plausible and interesting hypothesis. The sentence should therefore be reformulated in the conditional.

Comment n°10: The authors could strengthen their argument by acknowledging that rights-based approaches implementation additionally faces barriers that are, if not at all, indirectly related to cultural moral logics (e.g., lack of resources and infrastructures, institutional and political will, resistance to organisational change). Recognising the diversity of these obstacles would help situate the specific overarching contribution of the cultural lens proposed here, rather than leaving the impression that moral economy is the primary or sole obstacle.

2. Cultural Configurations Behind Contribution-Based Worth

Comment n°11: The use of Hofstede’s model is the most significant methodological concern in this section. The model is mobilised as though its cross-cultural validity were uncontested, whereas it has been subject to sustained and substantial criticism in the literature (e.g., McSweeney, 2002). The authors should clarify why the Hofstede framework remains a useful heuristic for their purposes despite these limitations.

McSweeney, B. (2002). Hofstede’s model of national cultural differences and their consequences: A triumph of faith-a failure of analysis. Human relations, 55(1), 89-118.

Comment n°12: The authors should clarify the epistemological status of this section at the outset. Are the three dimensions proposed (Restraint, Collectivism, Long-Term Orientation) a theoretical proposition from the authors, i.e., a framework they are putting forward, or a synthesis of well-established empirical findings? The answer shapes how the section should be read and evaluated.

Comment n°13: Lines 129–135, the authors claim that collectivist social logics produce resistance to receiving support without contributing. However, collectivist social contracts may equally imply an obligation to care for vulnerable members of the group. It is possible that contribution-based moralities create stigma and self-stigma without necessarily negatively impacting care per se (e.g., reducing access)? For example, individuals may receive care while simultaneously experiencing shame and internalised negative worth. This directly relates to comments n°6 and 7 above.

3. Japan as an Illustrative, Not Exceptional, Case

Comment n°14: Lines 166–168 introduce a claim that is in tension with the paper’s overarching argument: “Similar patterns appear across societies shaped by Confucian ethics, Protestant work ethics, socialist labour ideology, or strong family duty norms. What appears culturally specific is often structurally similar once we examine the underlying moral logic.” If the underlying moral logic is structurally similar across Confucian, Protestant, socialist, and family duty-based societies, what remains distinctively cultural about the phenomenon the authors are describing? The authors should clarify whether they are advancing a culturalist thesis or a thesis about universal moral logics that express themselves differently across contexts. This distinction has significant implications for the paper’s argument and for the strategies proposed.

4. The Clash with Rights-Based Mental Health

Comment n°15: Table 1 would benefit from clearer column labelling. As currently titled, the distinction between what the left column represents (aspirational principles) and what the right column represents (potential moral misreading in specific cultural contexts) is not immediately apparent. Suggested revision: “Rights-based principles/values” and “Contrasts within contribution-based moral economies.”

Comment n°16: Lines 179–181: “When they enter cultural contexts where worth is contribution-based, they create ethical dissonance” should be reformulated in the conditional, consistent with the general concern about epistemic marking raised above.

5. Integrating Moral Economies into Rights-Based Mental Health

Comment n°17: The five strategies are formulated at a level of generality that limits their operational usefulness, especially for a paper oriented toward implementation. The authors could illustrate each strategy with at least one concrete example drawn from existing programmes or documented experiences. This would make the contribution considerably more actionable for practitioners and policymakers.

Comment n°18: An internal tension in the proposed strategies should be acknowledged. Strategies 1 (broadening what counts as contribution) and 4 (using culturally credible narratives to renegotiate norms) both involve modifying the existing moral system, not merely adapting to it. This directly contradicts the principle of “working with the existing moral economy” stated at the outset of the section. The authors should explicitly address this. Perhaps the distinction is that these strategies seek to expand the moral economy from within, rather than replacing it: if so, this should be stated clearly.

Comment n°19: The framing at lines 194–197 “A culturally viable rights-based approach does not treat contribution-based moralities as simply “wrong” or to be replaced. Instead, it works with the existing moral economy, shifting what counts as contribution, and reframing support so that rights feel morally legitimate rather than morally risky” is conceptually sound and deserves more argumentative weight than it currently receives.

Comment n°20: Line 214: “Some terms and criteria inadvertently activate suspicions of undeserved reward”: an example or two would considerably clarify this claim.

Comment n°21: Lines 224–227: The recommendation to frame eligibility rules around participation rather than deficit formulations is interesting. A hypothetical example contrasting the two types of formulation would make this recommendation immediately usable.

6. Conclusion

Comment n°22: One point requires attention: the claim that the proposed approach “strengthens the cultural resonance, ethical grounding and practical viability” of human rights is too assertive. Suggestion is to exercise greater caution: “It has the potential to strengthen…” .

IV. Recommendation

Major revision. The paper addresses a genuine and important problem, and the central thesis has real potential to contribute to the global mental health literature. However, it requires substantial work on three fronts: conceptual clarification (particularly the definition and positioning of the moral economy framework, and the limits of the Hofstede model), epistemic rigour (consistent marking of the status of claims throughout the manuscript), and operationalisation of the proposed strategies.

I look forward to reviewing the revised manuscript and remain available should the authors require clarification on any of the points raised above.

Glob Ment Health (Camb). doi: 10.1017/gmh.2026.10255.pr4

Recommendation: The moral economy of worth: Why rights-based mental health must engage cultural logics of contribution — R0/PR4

Editor: Petr Winkler1

No accompanying comment.

Glob Ment Health (Camb). doi: 10.1017/gmh.2026.10255.pr5

Decision: The moral economy of worth: Why rights-based mental health must engage cultural logics of contribution — R0/PR5

Editor: Judith Bass1

No accompanying comment.

Glob Ment Health (Camb). doi: 10.1017/gmh.2026.10255.pr7

Review: The moral economy of worth: Why rights-based mental health must engage cultural logics of contribution — R1/PR7

Laurence Kirmayer 1

The author’s have responded well to the earlier reviews and the article makes a very important contribution. Their arguments are conssitent with in an earlier review (Kirmayer, L. J. (2012). Culture and context in human rights.In: udley, M., Silove, D., & Gale, F. (Eds.), Mental health and human rights: Vision, praxis and courage (pp. 95-112) Oxford Univeristy Press) but they have developed very useful suggestions for advanced rights-based mental health through close attention to culture.

Glob Ment Health (Camb). doi: 10.1017/gmh.2026.10255.pr8

Review: The moral economy of worth: Why rights-based mental health must engage cultural logics of contribution — R1/PR8

Anonymous

I thank the authors for having carefully addressed each of the points raised in the initial review. The responses are comprehensive, and demonstrate genuine engagement with the critiques formulated. The revisions brought to the manuscript, in particular the clarification of the moral economy framework, the more nuanced epistemic marking of claims throughout the text, the acknowledgement of the limitations of the Hofstede model, and the enrichment of the proposed strategies with concrete examples, substantially strengthen both the argumentative coherence and the practical value of the paper. The revised manuscript is considerably clearer in its theoretical positioning and more rigorous in its handling of the evidence. The concerns raised have been adequately addressed. My recommendation is to accept the manuscript for publication.

Glob Ment Health (Camb). doi: 10.1017/gmh.2026.10255.pr9

Recommendation: The moral economy of worth: Why rights-based mental health must engage cultural logics of contribution — R1/PR9

Editor: Petr Winkler1

Thank you for this valuable contribution to the global mental health discussion.

Glob Ment Health (Camb). doi: 10.1017/gmh.2026.10255.pr10

Decision: The moral economy of worth: Why rights-based mental health must engage cultural logics of contribution — R1/PR10

Editor: Judith Bass1

No accompanying comment.

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    Data Availability Statement

    This study did not involve the novel creation, generation, or analysis of primary research materials. All relevant literature is cited in the References.

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