CRITICAL REFLECTIONS ON THE POLITICS OF NEED:

IMPLICATIONS FOR PUBLIC HEALTH

ANN ROBERTSON

Department of Public Health Sciences, McMurrich Building, University of Toronto, Toronto, Ont.,Canada M5S 1A8

AbstractÐThis paper presents a case for an underlying language of need consistent with public health'scommitment to social justice. After examining the problem of human need as it has been conceptualisedhistorically, this paper argues that the problems of needs ± a central concern in the modern welfarestate ± are inherently political. Two ways of conceptualizing need which have dominated the recent dis-course on need ± namely a therapeutic language of need and rights talk ± are examined and found tobe unsatisfactory in capturing the sense in which needs and their de®nition and arbitration are centralto the life of the community. What is required for public health is a language of need which speaks tothe reciprocity and interdependence which characterise community; such a language is to be found in a``moral economy of interdependence''. The paper concludes by discussing what a moral economy ofinterdependence, as a language of need consistent with the aims of public health, might look like. #1998 Elsevier Science Ltd. All rights reserved

Key wordsÐpublic health, needs, moral economy, interdependence

INTRODUCTION

In the waning years of the millennium, we are

deluged with apocalyptic visions and scenarios. Oneof the more prevailing of these is the claim of ``®s-

cal crisis'' which, among other things, appears to bedriving the near universal dismantling of the welfare

state in most western industrialised nations. In thedomain of health, the notion of ``health carereform'' has received much attention in this last

decade of the 20th century, although what constitu-tes ``reform'' varies with the context. In the U.S.,

the unsuccessful health care reform agenda aimedat expanding universal health care insurance cover-

age beyond Medicare and Medicaid. In contrast,health care reform in Canada has generally meantthe narrowing of the universality of health care

insurance coverage by a number of provincial gov-ernments; this has involved such strategies as imple-

menting various kinds of ``user fees'' and narrowingthe comprehensiveness of coverage by ``delisting''

previously covered health care services such asmammography screening.

At the same time, public health has undergone asea of change in the last two decades. This is aresult primarily of the reframing of health pro-

motion to incorporate into public health theoryand practice concepts like ``empowerment'', ``com-

munity development'' and ``social determinants ofhealth''. Underwritten, largely by documents like

WHO discussion papers (WHO, 1986), The OttawaCharter (Government of Canada, 1986) and inCanada The Epp Report (Health and Welfare

Canada, 1986), this ``new'' public health places anemphasis on health inequalities and on the social,

political and economic determinants of those

inequalities in health. Many would argue that this

is not so much a new public health as a return to

the historical commitments of public health to

social justice (Szreter, 1988; Minkler, 1989; Terris,

1994).

Most students of public health are familiar with

the famous 1848 account by Rudolph Virchow of

the desperate living conditions of the people of

Upper Silesia, which he analysed as the real causes

of their health problems (Tesh, 1990). The great

sanitary movement in Britain at the end of the last

century was largely driven by health activists,

whose e�orts at reform were directed at the appal-

ling living and working conditions of the mass of

urban poor (Szreter, 1988). As a result of this

movement, important public health measures were

instituted ± ``water and sewage were regulated,

housing and factory codes were passes and child

labor was prohibited'' (Ellencweig and Yoshpe,

1984). And, attempts throughout the 20th century

to align public health with a social justice agenda

(see, for example, Nyswander, 1967; Beauchamp,

1976; Kickbusch, 1989; Minkler, 1989; Labonte,

1993; Terris, 1994) reveal the persistence of the

moral thrust of public health.

However, largely missing in current discussions

of the public health agenda is a consideration of

what lies at the core of the concern with public

health as social justice, namely the fundamental

issue of human need. The purpose of the present

paper is to critically examine the concept of human

need, in the interests of articulating a renewed

moral discourse for public health.

Soc. Sci. Med. Vol. 47, No. 10, pp. 1419±1430, 1998# 1998 Elsevier Science Ltd. All rights reserved

Printed in Great Britain0277-9536/98/$19.00+0.00

PII: S0277-9536(98)00255-X

1419

This paper begins with a brief discussion of someof the di�erent ways in which need has been con-

ceptualized historically. The second part of thispaper discusses the politics of need and explores thepossibilities for a language of need in the context of

the modern welfare state, one cornerstone of whichhas been public health. The paper concludes byo�ering a reconceptualization of need consistent

with the commitments of public health to social jus-tice.

THE QUESTION OF HUMAN NEED

To invoke the notion of need is to invoke what

may well be the most powerful rhetorical device ina social policy debate. To argue that ``X needs Y''is to imply the normative corollary that ``X should

have Y''. The concept of need, thus, carries with itan aura of moral suasion. Indeed, many of the clas-sical philosophers ± Plato, Aristotle, the Stoics and

the Epicureans ± ``argued that a man's characterand the moral condition of the culture from whichhe sprang could be judged by those values whichwere raised to the level of needs'' (Springborg,

1981, p. 9).Philosophers of the Hellenistic period were pri-

marily concerned with what constituted the ``good''

for human beings and how it could be achieved,however it was de®ned: for Aristotle, it was happi-ness; for Plato and the Stoics, it was wisdom; for

the Epicureans, it was pleasure (Springborg, 1981,Chap. 2). For all of them ± and for the schools ofthought that each has spawned ± a person's needs

were related to whatever principle was regarded asthe proper goal of human existence.A long philosophical tradition ± starting with

those early philosophers, extending through

Enlightenment philosophers like Jean-JacquesRousseau, the philosophy of John Locke and thenineteenth century Utilitarians and the early social-

ists to twentieth century philosophers such as Jean-Paul Sartre, Erich Fromm and Herbert Marcuse ±represents an ongoing discussion about the nature

and extent of human needs. One of the major his-torical debates about human need is: are needsobjective and, therefore, in some sense irrefutableor are they contingent and, therefore, always con-

testable?

The objectivity of human needs

The question of the objectivity of human need isinextricably tied up with questions of what constitu-tes human nature. If it can be demonstrated that

human nature consists in certain inescapable, incon-trovertible and, therefore, unalterable features orcharacteristics, then human needs ± that is, what

people require in order to be human ± are incon-testable, factual, inescapable. The ``givenness'' ofhuman nature means that ``there are natural limitsto the extent to which we can change ourselves...

[and] in this sense we have a human nature overwhich we have only limited control and choice''

(Thomson, 1987, p. 25).According to philosopher Garrett Thomson, who

provides a good contemporary philosophical argu-

ment for the objectivity of human need, we cannotvoluntarily give up our fundamental needs because,by de®nition, ``a need is inescapable if there is noth-

ing a person can do to escape it in the future and ifthere was nothing he could have done in the past tohave avoided its acquisition'' (Thomson, 1987, p.

29). Thus, needs are distinguished from desireswhich Thomson characterises as ``belief dependent''(Thomson, 1987, p. 67). Needs also are to be distin-guished from drives or instincts (Thomson, 1987, p.

13):

Drives, like desire, is a motivational concept used toexplain behaviour or action; need is not.... Moreover, thelack of things needed for survival or to avoid seriousharm will not necessarily cause drives and not all drivesare caused by the lack of things we need.

But, why should it be important to establishhuman needs as objective? The answer to thisappears to lie, in part, in the connection between

human needs and social justice. In her book, TheProblem of Human Need, Patricia Springborg main-tains that the concern with social justice and equal-

ity has characterised need theory every since theEuropean Enlightenment. Reaching back to theEpicureans and the Stoics, Enlightenment philoso-

phers grounded their arguments in ``natural laws'',because ``nature revealed order, rationality and har-mony, which made possible a ``scienti®c'' account

of human behaviour'' (Springborg, 1981, p. 15). Inseeking scienti®c explanations of human nature ± asopposed to metaphysical ones ± the early socialistssought to demonstrate that, if human nature could

be shown to consist of certain irrefutable innatecharacteristics, then the problem of human needswould be solved: our needs would ¯ow directly

from our nature and issues of social justice wouldthen be uncontestable.The link between human nature, human needs

and social justice as equality reached its most com-plete and, perhaps, its most passionate expressionin Marx's early writings (Springborg, 1981, p. 3±4;emphasis added).

In his emphasis on the ontological signi®cance of need,Marx is concerned to give an account of human essence,man's species-being, such that both the material andphysical constraints of human existence, as well as man'simmanent capacity to transcend these limits, areincluded... it is as ``needs'' that man experiences [the] pro-pensities of his nature...

The objectivity ± and, therefore, irrefutability ±of human needs, based on a scienti®c theory of

human nature as fundamental and given, meansthat for Marx ``needs represent both a teleologicalimperative and a motivational mechanism''(Springborg, 1981, p. 2). The pursuit of social jus-

A. M. Robertson1420

tice is, thus, rendered scienti®c and no longer has torely for its justi®cation on ethical systems. Marx

viewed ethical systems as always embedded in bour-geois morality, a morality which perpetuates thestatus quo in terms of an unequal distribution of

social goods, both material and non-material(Lukes, 1985). For Marx, it is the unfolding of``truly human needs'' which provides the impetus

for the necessary and historical progression ofindustrial society from capitalism through socialismto communism and, hence, greater social justice.

This brings us to another dilemma, for to suggestthat there exists ``true'' human needs is also tosuggest that there exists human needs which are nottrue. While a fuller discussion of the centuries old

debate over true vs. false needs is beyond the scopeof this paper, for the purposes of the ensuing dis-cussion one issue emerging from this debate will be

very brie¯y highlighted. Proponents of the twentiethcentury doctrine of false needs (for example,Fromm, 1947; Maslow, 1954; Marcuse, 1972;

Sartre, 1974; Illich, 1977, 1978) argue that the incul-cation of ever-expanding false needs under capital-ism has produced a new kind of person, one with a

``willing compliance as an insatiable consumer''(Springborg, 1981, p. 6). Moreover, it has beenargued that Marx's original notion of ``commodityfetishism'' has been replaced in the late twentieth

century with a ``services fetishism'', with its evengreater potential for an ever-expanding repertoire offalse needs (Illich, 1977).

In contrast, Springborg argues that the doctrineof false needs not only oversimpli®es the articula-tion of what human needs are, but also makes the

project of meeting them seem almost futile, for ``thedoctrine denies the ethical character of [social] pro-blems and puts their appropriate solution furtherout of reach... therefore beyond the rational scru-

tiny and control or responsibility, of the individual''(Springborg, 1981, p. 250). In addition, as I shallargue later, it takes the problem of human need out

of the social and political realm and, therefore,beyond the community.Again, we are led to ask: why this great e�ort to

establish, once and for all, that human needs areirrefutable and therefore objective? One answerappears to be that if the problem of human needs

can be framed as an objective technical problembased on empirical knowledge ± as much contem-porary social policy analysis attempts to do ± thenwe can avoid the ``messiness'' of politics. An

alternative to the view of human need as objectiveis the notion that human needs are inherently politi-cal.

The political nature of needs

Through politics, a society decides whether needs are realor legitimate (Stone, 1988, p. 80).

Political solutions to the problem of humanneeds involve people with all their con¯icting views,

are fraught with uncertainty and ambiguity andtake time. In addition, as political philosopherMichael Walzer says (Walzer, 1983, p. 66; emphasis

added):

Despite the inherent forcefulness of the word, needs areelusive. People don't just have needs, they have ideas abouttheir needs; they have priorities, they have degrees of need;and these priorities and degrees are related not only totheir human nature but also to their history and culture.

In other words, human needs are both ¯uid andcontingent. In political scientist Deborah Stone's

analysis of human needs (Stone, 1988, Chap. 4), itis not so much whether or not particular needs aretrue (or false) as it is whether or not particular

needs are judged to be legitimate. Stone o�ers achallenge to the notion that needs can be deter-mined empirically ± and are thus objective ± on the

basis of ®ve dimensions of human need which arebrie¯y discussed below.The most important challenge to the notion of

the objectivity of needs is that, because human

needs are always located within a particular histori-cal and cultural context, needs have a symboliccharacter. Even food ± the one need always

included on minimalist's list of human needs ± ``isnot just calories, but a sign of membership, socialstatus and spiritual worth'' (Stone, 1988, p. 71).

Because needs have a symbolic character, theyare relative as well as absolute. Stone says that``almost all needs are relative in the sense that

people de®ne them in accordance with communitystandards, norms and customs'' (Stone, 1988, p.73). Deprivation is felt not in absolute terms butrather in terms of comparison to some reference

group. Recent empirical evidence indicating the as-sociation of health inequalities with the relative sizeof the ``wealth gap'' for a number of developed

countries appears to support this observation(Wilkinson, 1994).Some of our needs are instrumental in that, while

they are not necessary for our physical survival likefood and shelter, they, nevertheless, are importantbecause they indirectly enable us to obtain what weneed. In a market economy, where the primary dis-

tributive mechanism is work-based (Stone, 1984),people need jobs. Likewise, education and healthcare can be justi®ed on the grounds that these

enable people to work in order to provide for theirbasic needs of food and shelter. And, it has beenargued further that health itself is a need, required

for active participation in the life of the community(Kickbusch, 1989; Doyal and Gough, 1991).Protection from potential harm in the future

recently has lent need another dimension not con-sidered in discussions of need prior to the 20thCentury. Much of current safety regulations ± seatbelt and child restraint laws, workplace safety and

Critical re¯ections on the politics of need 1421

most public health e�orts ± address this futureaspect of need.

In the view of many (Ignatie�, 1984; Bellah et al.,1985; Kingson et al., 1986) our most truly humanneeds ± and those which are the most di�cult to

articulate ± are communal needs. Stone (Stone,1988, p. 77) characterises communal needs as thoseneeds which go beyond mere individual physical

survival and which re¯ect our need for community,reciprocity, mutuality and interdependence.The ®ve dimensions of need, discussed above rep-

resent di�erent ways of conceptualizing need;undoubtedly there are other ways to do so. Thepoint is that, because there are many ways of think-ing about need ± that is, ideas about needs ± the

de®nition of and discussion about need necessarilybecomes ``an exercise in political claims-making''(Stone, 1988, p. 80).

When we admit the inherently political characterof human needs, it is not that needs then become``voracious and undisciplined'' (Stone, 1988, p. 79)

or ``false'' and ``arti®cial''; rather, it is that needsbecome in®nitely contestable. This view of needmight send those who would argue for the objectiv-

ity of human needs into a tailspin of despair, butfor those who characterise need as inherently politi-cal (Walzer, 1983; Ignatie�, 1984; Stone, 1988), itspeaks to the true business of politics ± the me-

diation of competing need claims. As Springborgsays, ``the problem is... ®nding social mechanismsto mediate between the con¯icting needs which

necessarily arise'' (Springborg, 1981, p. 250). Thewelfare state of western industrialised nations rep-resents one such social mechanism.

THE POLITICS OF NEED: FROM THE WELFARE STATETO COMMUNITY

The dilemma of the modern welfare state

At the heart of the modern welfare state is whatDeborah Stone has called a ``distributive dilemma''(Stone, 1984, p. 15). The primary distributive sys-

tem in market societies ± which characterises mostdeveloped nations, capitalist as well as socialist ± iswork-based: labour is a commodity and peoplework in order to acquire what they need. However,

labour markets never function perfectly; nor canthe work-based system meet the needs of peoplewho cannot work or who cannot work enough.

This necessitates the development of a need-basedsystem of distribution to ameliorate the failures ofthe work-based distribution system.

Need-based systems: residual vs. institutional socialsecurity. Need-based distributive systems haveevolved in a number of ways in various modern

welfare states. In his discussion of the developmentof social security in Canada, Dennis Guest (Guest,1980) distinguishes between two major policyalternatives for distributing the wealth, goods and

services produced by a society. The ®rst methodwhich prevailed in Canada ± and most other wes-

tern industrialised countries ± until the 1930s heldthat the private market was the most appropriateand just method for distribution.

Supported by the values of individualism, self-re-liance and personal liberty, the role of the state wasprimarily to ensure the freedom of the free-enter-

prise market system through a policy of non-inter-vention. Relief or assistance to the unfortunatemembers of the society ± the poor, the sick, the dis-

abled, the old, the unemployed ± was left tofamilies and local municipalities, was consideredtemporary, carried a heavy stigma and wasregarded as evidence of personal failure. In combi-

nation with this residual social security system, theprivate market system was thought to exercise acertain kind of justice, albeit harsh, by rewarding

hard work, thrift and independence. This wasthought to enhance the prosperity of individuals,families and the community.

It was after the experience of the Depression andWorld War II, that the modern welfare state basedon institutional social security came into its fullest

expression. Institutional social security acknowl-edges that the costs of industrial and economic pro-gress are borne by some members of society andnot others and that people may become unem-

ployed, poor or otherwise disadvantaged throughno fault of their own. Society as a whole is obli-gated to take responsibility for its vulnerable mem-

bers in the form of publicly funded programs whichprotect people against adversity. Guest expressesthe moral under-pinnings of institutional social

security when he says ``there is a duty on the partof a civilized society to see that the costs and ben-e®ts of industrial progress are shared by all''(Guest, 1980, p. 3).

Institutional social security is characterised by agovernment that takes an active redistributive rolein order to redress inequalities between people. This

typically occurs through two primary redistributivemechanisms: income security programs, such as oldage pensions and unemployment insurance; and

publicly ®nanced social programs, such as healthcare. The establishment of institutional social secur-ity, however, raises a fundamental ideological issue

which underlies all policy discussions about redistri-butive bene®ts to meet needs: selectivity vs. univers-ality.

Selectivity vs. universality

Selective (or ``targeted'') public bene®ts are those

which are provided to individuals or families whocannot a�ord to pay for them; individuals orfamilies who can a�ord to purchase these bene®ts

do so in the private market. Medicare andMedicaid in the U.S. operate on this principle ofselectivity, as do many welfare programs such asthe Aid to Families with Dependent Children

A. M. Robertson1422

(AFDC) program. Universal bene®ts are thosewhich are provided to everybody regardless of

income. Health insurance in Canada operates fromthe principle of universality, as does education inboth the U.S. and Canada.

Although those with money have always beenable to purchase their way out of universal publicprograms like education, nevertheless the point

about universal public programs is that they areavailable to all as an entitlement of citizenship.Thus, they lack the stigma ± in Erving Go�man's

sense of ``spoiled identity'' (Go�man, 1963) ± thatselective public programs confer on their recipients.It is to the social policy writings of RichardTitmuss (Titmuss, 1963, 1968, 1973, 1974; Reisman,

1977; Abel-Smith and Titmuss, 1987) that we turnto gain insight into the social and political signi®-cance of the issue of selectivity vs. universality.

As a passionate defender of the post-war welfarestate in Britain, Titmuss understood that the stig-matization conferred by selective social programs

can lead to a socially constructed dependency withan attendant loss of dignity. Titmuss believed in a``social theory of causality'' of misfortune and that

the disadvantaged are ``the social pathologies ofother people's progress'' (Titmuss, 1968, p. 134).Calling this phenomenon ``diswelfare'', Titmuss wasconfronting head-on the social Darwinism that had

been the ideological underpinning of British welfarepolicy since the 1834 Amendment to the PoorLaws. His justi®cation for the provision of universal

social programs was based on his notion of thesocial causes of diswelfare (Titmuss, 1968, p. 119;emphasis added):

The emphasis today on ``welfare'' and the ``bene®ts of wel-fare'' often tends to obscure the fundamental fact that formany consumers the services... represent partial compen-sation for disservices, for social costs and social insecuri-ties which are the product of a rapidly changingindustrial-urban society. They are part of the price we payto some people for bearing part of the cost of other people'sprogress.

Titmuss believed that it should be an objective of

all social policy to ``build the identity of a personaround some community with which he is associ-ated'' (Titmuss, 1974, p. 38), arguing that the mar-

ket mechanism is too competitive and tooindividualistic to facilitate community and involve-ment (see also Beauchamp (1976) for a critique of

market justice). Titmuss advocated for universal``social institutions that foster integration and dis-courage alienation'' (Titmuss, 1968, p. 133), in thebelief that (Reisman, 1977, p. 69):

... man, a sociable as well as a social animal, is happiestwhen most integrated in the group. Social policy oughttherefore to be seen as being concerned not simply withthe relief of individual needs but with the furtherance of asensation of common citizenship...

Titmuss also had a pragmatic political reason forarguing against selectivity and for the principle of

universality. He felt that it was essential for the pol-itical legitimacy of social programs to ensure the

ideological support and commitment of the largemiddle class, who not only would pay for these pro-grams through their taxes, but who also would reap

considerable bene®ts from them. More importantly,universal social programs were not ®scally feasiblewithout this broad-based political support.

Titmuss defends the welfare state on the basis ofits integrative function and resulting positive e�ectson community solidarity. Institutionalized redistri-

bution, with all its attendant bureaucratic evils,acknowledges in a profound way the moral groundsof our interconnectedness. In The Needs ofStrangers, historian Michael Ignatie� also acknowl-

edges the moral underpinnings of the welfare statewhen he says, ``the moral relations that existbetween my income and the needs of strangers at

my door pass through the arteries of the state''(Ignatie�, 1984, p. 141). However, he also arguesthat while the welfare state has relieved and

absolved each of us ± giver and receiver ± from theburden of ``®ckle'' individual acts of charity, ``inmany Western welfare states, entitlements are still

perceived both by the giver and the receiver, asgifts'' (Ignatie�, 1984, p. 16). In order to resolvethis dilemma, he challenges us to ®nd a language ofneed ``adequate to the times we live in'' (Ignatie�,

1984, p. 141). The remainder of this paper is anattempt to respond to that challenge.

The language of needs

Ignatie� says that it is in ``needs language'' that``a particular kind of language of the human good''

(Ignatie�, 1984, p. 14) can be found. Echoing theearly Marx, he elaborates (Ignatie�, 1984, p. 15):

In the end, a theory of human needs has to be premisedon some set of choices about what humans need in orderto be human: not what they need to be happy or free,since these are subsidiary goals, but what they need inorder to realize the full extent of their potential.

While there never can be ``any eternally validaccount of what it means to be human'', we do

have a ``historical record of what men have valuedmost in human life'', embodied in words like ``love,respect, honour, dignity, solidarity with others''(Ignatie�, 1984, p. 15). However, as Ignatie� also

says, ``modern life has changed the possibilities ofcivic solidarity and our language stumbles behindlike an overburdened porter with a mountain of old

cases'' (Ignatie�, 1984, p. 138).Two of these ``old cases'', which have dominated

our discourse on need in the last half of the twenti-

eth century and which require ``unpacking'' are atherapeutic language of need and ``rights talk''.A therapeutic language of need. Sociologist John

O'Neill says that our service society ``is underwrit-ten by its industrial, legal and medical technologyand a variety of neo-individualist ideologies thatseek to reshape our notions of men, women and

Critical re¯ections on the politics of need 1423

children, from familied beings into beings whose

rights and duties are de®ned through the thera-

peutic state'' (O'Neill, 1985, p. 85). This therapeutic

state is characterised by a service ethic in which,

according to social activist McKnight (1977), per-

sons are remade as clients or patients, that is as

holders and collections of professionally-de®ned

needs. Ivan Illich has characterised our age as an

age of ``disabling professions'' in which people had

``problems'', experts had ``solutions'' and scientists

measured imponderables such as ``abilities'' and

``needs'' (Illich, 1977, p. 11) and also as ``an age

when needs were shaped by professional design''

(Illich, 1977, p. 13). In other words, in the late 20th

century we have witnessed the commodi®cation of

need itself (see Beauchamp, 1988 for a discussion of

this as it relates to public health).

The social implications of a therapeutic conceptu-

alization and the consequent commodi®cation of

human need are addressed by Bellah et al., 1985, in

their book Habits of the Heart. According to the

authors, the therapeutic mode which pervades both

our private and public lives, is characterized, in

part, by an attitude that all relationships and all ac-

tivities are merely means to the end of self-realiz-

ation, the goal of life. Manifested as an ascetic

social contractualism in which commitments are

made by freely choosing individuals, such an atti-

tude, they claim, has resulted in the erosion of pub-

lic and civic life, for ``in its quest to reunify the self,

the therapeutic attitude distances us from particular

social roles, relationships and practices'' (Bellah et

al., 1985, p. 127).

When people are fragmented into clients of a

therapeutic service system, ``citizens no longer

exist'' (McKnight, 1977, p. 85), the ``commons are

extinguished'' (Illich, 1977, p. 27) and politics is,

indeed, in danger of withering away.

Rights talk. A fundamental question which ariseswhen speaking of needs is: do needs always imply

rights? In their monograph On the RelationshipBetween Human Rights and Human Needs, Galtangand Wirak, 1978 characterise needs as ``something

located inside individual human beings'' whereasrights are ``something located between them'' (Gal-tang and Wirak, 1978, p. 1). As social norms, rights

are what needs become when they enter the socialand political arena. Feminist philosopher NancyFraser goes further in saying ``I would argue in

favor of the translatability of justi®ed needs claimsinto social rights'' (Fraser, 1990, p. 180).According to Galtung and Wirak, the human

rights tradition has been most active and e�ective

when the need satisfaction of some ± life, liberty,employment, etc. ± is impeded by the deliberateacts of others. Many of the identity-based rights

movements of the late twentieth century (forexample, civil rights, women's rights, gay rights, dis-ability rights) can be regarded as having been suc-

cessful in transforming human needs into rights ofcitizenship. However, as Galtang and Wirak say(Galtang and Wirak, 1978, p. 15):

... the relationship is not a simple or very neat one.Rather, the rights are the means and satisfaction of needsis the end and like all other means-end relationships therelationship is complicated.

With his highly in¯uential 1971 book, A Theory

of Justice, American political philosopher Rawls,1971 was instrumental in reinvigorating Anglo-American discussion of needs as rights in the late

twentieth century (see also Nozick, 1974; Dworkin,1977). Rawls considers rights as primary socialgoods ± along with liberties, opportunities andpowers, income and wealth ± because ``with more

of these goods men [sic] can generally be assured ofgreater success in carrying out their intentions andadvancing their ends, whatever these ends may be''

(Rawls, 1971, p. 92). In other words, guaranteeingneeds as rights enables people to realize their indi-vidual potential*.

While a fuller discussion of the social and politi-cal issues raised by Rawls and others in this neo-lib-eral tradition is beyond the scope of this paper, it isimportant to note that there have been many cri-

tiques by communitarians (Bellah et al., 1991;Glendon, 1991), feminists (see especially, (Frazerand Lacey, 1993; Frazer and Lacey, 1995) and

others (Sandel, 1982; Walzer, 1983; MacIntyre,1984) of the Rawlsian view on individual rights as afundamental principle of justice. To begin with, im-

plicit in this view is the Kantian notion that themoral status of the individual is irreducible and pre-social, a concept at the heart of liberalism (see

Frazer and Lacey, 1993 for an excellent critique ofthis particular aspect of the Rawlsian position). Interms of health, this is to ignore the very real e�ectsof gender, race, class and other social designations

*Rawls essentially builds his case for distributive justiceon this notion of primary social goods, includingrights, on a heuristic device he calls ``the original posi-ton'' in which people choose the principles of justicefrom behind a ``veil of ignorance'' about the details ofthe society in which they are situated and their ownparticular social location in that society. Relationsbetween people are, thus, conceived as fundamentallyasocial ± that is, as free associations between self-deter-mining individuals. An example of this kind of think-ing in the health ®eld can be found in the work ofNorman Daniels (see, especially, (Daniels, 1985, 1988).In Am I My Parents' Keeper, Daniels takes a Rawlsianapproach in developing his prudential life-span accountfor the intergenerational distribution of health care.Basing his argument on the liberal principle of theautonomy of the individual, Daniels argues that, sincewe all grow old, what appears to be transfers betweenage groups ± from the young to the old ± are actuallytransfers ``within lifetimes'' (p. 63). He thus reframesthe issue of intergenerational transfers as an ``intra per-son contract rather than an inter person contract'' (p.157).

A. M. Robertson1424

of persons on health status and health outcomes.More importantly for this discussion, the liberal

view of rights dismisses the signi®cance of our com-mon life together and the values of public life. Sucha critique is to be found in the work of Harvard

law professor, Mary Ann Glendon.In her 1991 book, Rights Talk: The

Impoverishment of Political Discourse, Glendon cri-

tically examines the dominant political discourse inthe U.S. in terms of the ``tendency to speak of whatis most important to us in terms of rights and to

frame nearly every social controversy as a clash ofrights'' (Glendon, 1991, p. 4). In policy debates aswell as in everyday conversation, claims are madeand heard ``that whatever right is under discussion

at the moment trumps every other consideration''(Glendon, 1991, p. 8).According to Glendon, American rights talk is

characterised by a rhetoric which includes: an abso-luteness which heightens social con¯ict and pre-cludes even the possibility of ®nding common

ground; a resounding silence concerning responsibil-ities ± both personal and civic; a ``relentless indivi-dualism'' which conceives of the individual as a

lone rights-bearer (Glendon, 1991, Chap. 3) andwhich, as a result, ``fosters a climate that is inhospi-table to society's losers and that systematically dis-advantages caretakers and dependents, both young

and old'' (Glendon, 1991, p. 14); a neglect of civilsociety ± families, neighbourhoods, ethnic and reli-gious associations and the like ± which Glendon

believes to be ``the principal seedbeds of civic andpersonal virtue'' (Glendon, 1991, p. 14) where``human character, competence and capacity for

citizenship are formed'' (Glendon, 1991, p. 109);and, ®nally, by an insularity from the moral andpolitical discussions taking place in other westerncountries with a similar political and philosophical

heritage.Rights-based language ultimately is an impover-

ished language of need. Ignatie� makes a distinc-

tion between ``needs which can be speci®ed in alanguage of political and social rights and thosewhich cannot'' (Ignatie�, 1984, p. 13). He believes

that our deepest human needs, those needs withoutwhich we cannot be human ± ``love, respect, hon-our, dignity, solidarity with others'' (Ignatie�, 1984,

p. 15) ± are also those which the ``individualist biasof our language of rights and entitlements makes itdi�cult to grasp'' (Ignatie�, 1984, p. 17). Rights-based language ``has no terms for those dimensions

of the human good which require acts of virtueunspeci®able as a legal or civil obligation''(Ignatie�, 1984, p. 14) and rights-based language

does not allow us to express communal needs(Ignatie�, 1984, p. 13):

Rights language o�ers a rich vernacular for the claims anindividual may make on or against the collectivity, but itis relatively impoverished as a means of expressing individ-uals' needs for the collectivity...

Finally, rights-based language acknowledges onlythe person who makes a claim against the collective;

it rarely considers those against whom the claim ismade. In other words, the language of rightsacknowledges only one side of the reciprocity

equation and says nothing about the responsibilitywe bear towards one another as members of thesame community. Ironically then, rights talk ulti-

mately depoliticizes need. This depoliticization ofneed deprives the community of its vitality andintensity and its members of a sense of participation

in the life of the community.In order to acknowledge the political nature of

human needs we require a new language of needs, alanguage in which the discourse on need is taken

out of the marketplace where needs are commodi-®ed and out of the courts where needs are reframedas rights. It is to the relationship between need and

the life of the community that we look for arenewed language of need.

Needs and the life of the community

It could be said that the recognition of the exist-

ence of fundamental human needs represents theunderlying catalyst for the formation of all humancommunities. Hegel characterised civil society as a``system of needs'' (Springborg, 1981, p. 77). As

Stone says: ``much of politics is... an e�ort to de®neneed collectively'' (Stone, 1988, p. 81). Indeed, itcould be argued that the primary purpose of poli-

tics is the de®nition and discussion of issues ofhuman needs, for ``the social contract is an agree-ment to reach decisions together about what goods

are necessary to our common life and then to pro-vide those goods for one another'' (Walzer, 1983, p.65).Those needs which a society or community deci-

des are necessary to the common life, Stone calls``public needs'' (Stone, 1988, p. 81). About theseneeds, she says (Stone, 1988, p. 81):

The pattern of public needs is the signature of a society.In its de®nition of public needs, a society says what itmeans to be human and to have dignity in that culture.

Politics is not only about the collective de®nitionand discussion of public needs; it is also about howa community de®nes and recognizes itself as a com-

munity. It could be argued that any group or com-munity is essentially characterized by the kinds ofneeds it collectively provides for and the extent to

which it provides for those needs. As political philo-sopher Michael Walzer puts it (Walzer, 1983, p.64):

Political community for the sake of provision, provisionfor the sake of community: the process works both waysand that is perhaps its crucial feature.

In other words, there is no collective provision ofneeds without community; nor is there any commu-nity without the collective provision of needs. It isthe de®nition and collective provision of human

Critical re¯ections on the politics of need 1425

needs which determines the cohesiveness ± or lackthereof ± of any group or community. Indeed,

Stone considers that ``communal provision... maybe the most important force holding communitiestogether'' (Stone, 1988, p. 82).

In a similar spirit and in opposition to the pre-vailing economic view of human behaviour*,Ignatie� says (Ignatie�, 1984, p. 17; emphasis

added):

It is as common for us to need things on behalf of others,to need good schools for the sake of our children, safestreets for the sake of our neighbours, decent old people'shomes for the strangers at our door, as it is for us to needthem for ourselves. The deepest motivational springs of pol-itical involvement are to be located in this human capacityto feel needs for others.

The needs that a community decides to take col-lective responsibility for says much about who isincluded in the community. Indeed, Walzer con-

siders that it is through the collective provision ofpublic needs that the community recognizes mem-bership in the community. In addition, the extent of

and inclusiveness in the discussion about need inany particular community is signi®cant, for ``whenall the members share in the business of interpretingthe social contract, the result will be a more or less

extensive system of communal provision'' (Walzer,1983, p. 83).

A RENEWED LANGUAGE OF NEED FOR PUBLIC HEALTH

It has been argued that public health is funda-

mentally about community and about the sharedvalues of life, health and security (Ignatie�, 1984, p.17). Dan Beauchamp argues further that ``theemphasis in public health on common measures to

protect the health and safety of the communitymakes public health measures ``collective goods''''(Beauchamp, 1983, p. 78). It is in this sense that the

language of public health is bound up with alanguage of need. This paper ends by exploring thepossibility of a renewed language of need appropri-

ate for public health.

Moral economy: The notion of reciprocity

The moral issue at the heart of the modern wel-fare society is: when does need entitle people tomake a claim against the collective? Any given soci-

ety's answer to this question is embodied in whathas been called the ``moral economy''. Martin

Kohli describes moral economy as ``the collectivelyshared basic moral assumptions constituting a sys-tem of reciprocal relations'' (Kohli, 1991, p. 275);

that is, it is about our ``collectively shared assump-tions de®ning norms of reciprocity'' (Minkler andCole, 1991, p. 38). Stone characterises the concept

of moral economy thus (Stone, 1984, p. 19):

The moral economy of a society is its set of beliefs aboutwhat constitutes just exchange: not only about how econ-omic exchange is to be conducted in normal times butalso,... when poor individuals are entitled to social aid,when better-o� people are obligated to provide aid andwhat kinds of claims anyone ± landowners, employer, gov-ernments ± can legitimately make on the surplus productof anyone else.

In his book The Gift Relationship, Titmuss uses

the case of voluntary blood donation to provide aneloquent articulation of what shared assumptions ofreciprocity might look like (Titmuss, 1973, p. 269;

emphasis added):

In not asking for or expecting any payment of moneythese donors signi®ed their belief in the willingness ofother men to act altruistically in the future and to com-bine together to make a gift freely available should theyhave a need for it. By expressing con®dence in the beha-viour of future unknown strangers they were thus denyingthe Hobbesian thesis that men are devoid of any distinctivelymoral sense.

In contrast to what Bellah et al. call a ``giving/getting'' notion of reciprocity or to more narrowlybased discussions of rights and entitlements, theconcept of moral economy is as much about our

obligations to one another as it is about the claimswe are entitled to make against each other. In otherwords, the language of moral economy acknowl-

edges both sides of the reciprocity equation.The currently popular concept of ``social capital''

(Putnam, 1993a,b, 1995, 1996) and the related

notion of ``social cohesion'' (Wilkinson, 1996) alsoinvoke moral economy notions of reciprocity.Social capital ``refers to features of social organiz-ation, such as networks, norms and trust, that fa-

cilitate coordination and cooperation for mutualbene®t'' (Putnam, 1993b, p. 35, 36). EchoingGlendon, Putnam regards social capital, created

through civic engagement as a public good which,unlike physical capital, increases with use. As hesays, ``a society that relies on generalized reciprocity

is more e�cient than a distrustful one...'' (Putnam,1993b, p. 37){.Clearly, this way of thinking about reciprocity

di�ers signi®cantly from liberal or marketplacenotions of reciprocity, for it acknowledges ourshared life in common and, thus, our fundamentalinterdependence.

*However, for a challenge to the neo-classical economicsview of ``economic man'' as a rational actor whomakes individual rational choices in the marketplace ofgoods and services on the basis of endogenous prefer-ences, see A Quiet Revolution in Welfare Economics(Hahnel and Albert, 1990).

{While a fuller discussion of the current debate about therelated concepts of ``social capital'' and ``social cohe-sion'' (see, for example, Brinkley, 1996; Greeley, 1997;Heying, 1997; Kaminer, 1997) is beyond the scope ofthis paper, it is important to note here that it has beenexplicitly linked to health (Wilkinson, 1996; Kawachiet al., 1997).

A. M. Robertson1426

Interdependence: beyond the dependence/indepen-dence dichotomy

The issue of ``dependency'' underlies the majorityof social policy debate in the modern welfare state.

Most welfare policy is made on the basis that to be``dependent'' is bad and to be ``independent'' isgood. One of the more signi®cant legacies from the

European Enlightenment ± in terms of its socialand political implications ± which informs mostcontemporary liberal debate is a radical individual-

ism in which the individual is regarded both as a``lone rights bearer'' (Glendon, 1991) and as anautonomous moral agent (Sandel, 1982; MacIntyre,1984). Deriving from Locke's and Rousseau's

notion of ``natural man'' as a solitary self-su�cientcreature and Kant's notion of man as a freelychoosing, rational actor, this kind of individualism

pays ``extraordinary homage to independence andself-su�ciency, based on an image of the rights-bearer as a self-determining, unencumbered, indi-

vidual, a being connected to others only by choice''(Glendon, 1991, p. 48).For all the symbolic power of the rhetoric of

independence, as Glendon (Glendon, 1991, p. 48)

wryly observes, this mythic lone individual ``pos-sesses little resemblance to any living man and evenless to most women''. The concept of interdepen-

dence, on the other hand, embraces the notion thatour good or bad fortune, our achievements or fail-ures are never entirely ``ours''. In his book

Liberalism and the Limits of Justice, Sandel writesof our indebtedness ± and, therefore, reciprocal ob-ligation ± to others in the larger context within

which we live (Sandel, 1982, p. 143; emphasisadded).

... it seems reasonable to suppose that what at ®rst glanceappears as ``my'' assets are more properly described ascommon assets in some sense; since others made me andin various ways continue to make me, the person I am, itseems appropriate to regard them, in so far as I can ident-ify them, as participants in ``my'' achievements and com-mon bene®ciaries of the rewards they bring.... [Thus] wemay come to regard ourselves... as participants in a commonidentity, be it a family or community or class or people ornation.

In other words, the fact that we live in commu-nities means that we are ipso facto interdependent.

The modern welfare state, as argued earlier, rep-resents an administrative attempt to extend thisconcept of interdependence to ``the strangers at my

door'' (Ignatie�, 1984) for, as Doyal and Harrissay, ``humanity is the gift of society to the individ-ual'' (cited in Doyal and Gough, 1991, p. 78).

By transcending the dependence/independencedichotomy with the concept of interdependence, wecut to the essence of human need in the context of

the community. This paper concludes with a briefdiscussion of what a moral economy of interdepen-dence ± as an alternative language of need ± mightlook like for public health.

Towards a moral economy of interdependence

... individual freedom and the general welfare alike dependon the condition of the ®ne texture of civil society ± on afragile ecology for which we have no name (Glendon,1991, p. 109 110).

I suggest that ``for which we have no name'' benamed a ``moral economy of interdependence''.

But, what are the implications for public health ofthis way of framing discussions of human need?First of all, we must readmit the language of

moral reasoning into discussions of public health

policy and practice. Moral and political languagehas been replaced, in part, by therapeutic language.Because the therapeutic self de®nes situations in

terms of its own wishes and wants, the question isnot ``Is this right or wrong?'' but rather ``Does thiswork for me?'' (Bellah et al., 1985, p. 141)

In asserting a radical pluralism and the uniqueness of eachindividual, [the therapeutically inclined] conclude thatthere is no moral common ground and therefore no publicrelevance of morality outside the sphere of minimal pro-cedural rules and obligations not to injure.

The result of this kind of thinking is a kind ofmoral relativism or perhaps more accurately a kind

of moral nihilism. It is di�cult to imagine how anynotion of community ± or, indeed, vision for publichealth ± can be built on the basis of a therapeutic

language.Recent attempts by philosophers, communitar-

ians, feminists and others to revitalize political dis-course with moral reasoning (Sandel, 1982;

Ignatie�, 1984; MacIntyre, 1984; Bellah et al., 1985;Fraser, 1990; Bellah et al., 1991; Glendon, 1991;Frazer and Lacey, 1993; Friedman, 1993; Tronto,

1993) all dismiss the liberal notion of the individualas an autonomous moral agent and seek to placethe individual back into the moral context of the

community. In his book After Virtue, philosopherAlasdair MacIntyre argues for a social moralitysaying that ``the only grounds for the authority oflaws and virtues, can only be discovered by entering

into those relationships which constitute commu-nities whose central bond is a shared vision of andunderstanding of goods'' (MacIntyre, 1984, p. 258).

A moral economy of interdependence would alsoseek to decommodify the notion of reciprocity, byrecognizing that not all human exchanges can be

entered into a cost-bene®t analysis. These wouldinclude love, time, energy, kindness, commitment,shared memories, care ± all the things which con-

stellate human relationships and create community.The relative absence of these kinds of consider-ations in most public health policy discussions hassigni®cant implications for issues of equity and

social justice. As British aging policy analyst AlanWalker says, speaking speci®cally of the care of theelderly (Walker, 1990, p. 385):

Since the commodi®ed form of social relations implicit inneo-classical economics undervalues both the role of older

Critical re¯ections on the politics of need 1427

people and the unpaid work of carers (more important inthe life worlds of older people than formal care), there isan antagonistic relationship between the needs of olderpeople and their families and the assumptions underlyingmacroeconomic policy. In other words, raw neo-classicalmacroeconomics is unlikely to produce an equitable out-come in resource distribution for older people (or anyoneelse for that matter).

A moral economy of interdependence not only

would take need out of the marketplace where it iscommodi®ed, it also would take it out of the courtswhere needs are reconceptualized as rights. Arguing

that ``our rights-laden public discourse easily ac-commodates the economic, the immediate and thepersonal dimensions of a problem, while it regularlyneglects the moral, the long-term and the social im-

plications'' (Glendon, 1991, p. 171), Glendon advo-cates balancing the rhetoric of rights with thelanguage of responsibility and reciprocity. It is for

this reason that many contemporary social policyanalysts (Ignatie�, 1984; Bellah et al., 1985; Reich,1988; Stone, 1988; Glendon, 1991) argue for a repo-

liticization of need by placing the discussion andarbitration of issues of need back into the polis*.To repoliticize need would mean to curb the

power of the ``experts'' and the growth of the

``therapeutic state''. This means that people andcommunities must be involved in determining theirown needs and the most appropriate ways to meet

them. Educators, community organizers and publichealth activists like Freire (1988), Alinsky (1972),McKnight (1987) and Minkler (1990) demonstrate

ways in which this can be accomplished. Healthpromotion concepts such as ``empowerment''(Wallerstein, 1992; Labonte, 1993) and ``community

development'' (Beattie, 1986; Farrant, 1986; Lotz,1987) and public health initiatives like ``HealthyCities'' (Duhl, 1986; Ashton, 1993) represent e�ortsto repoliticize need within the health domain.

CONCLUSION

This paper has engaged in a critical examinationof the politics of need in the context of the modern

welfare state in general and in relation to publichealth in particular. It also has explored the possi-bility of a language of need appropriate to the aims

of public health and o�ers ``a moral economy ofinterdependence'' as a possible language.Others have invoked the principle of interdepen-

dence in relation to public health. In arguing for an

ecological base for public health, Kickbusch(Kickbusch, 1989, p. 265) says that ``interdepen-

dence is central to ecological thinking''. In ecologi-cal terms, health is seen as ``a fundamental resourceto the individual, the community and to society''

(Kickbusch, 1989, p. 267). Furthermore, Doyal andGough argue that ``the protection of the health ofindividuals, their learning and the growth of their

emotional maturity are themselves social processes''(Doyal and Gough, 1991, p. 79). Health is thusboth a necessary prerequisite for and a product of

active citizenship.From its beginnings, public health has been fun-

damentally a moral enterprise, orienting its e�ortstowards improving the life chances of the most dis-

advantaged of society's members. There is anincreasing body of evidence that it is wealth andsocial inequalities which create health inequalities

(Wilkinson, 1996) (also see the entire issue of theBritish Medical Journal, Volume 312, April 20,1996 for an in-depth discussion). But as one writer

so eloquently puts it: ``the growing gap betweenrich and poor has not been ordained by extraterres-trial beings. It has been created by the policies of

governments'' (Montague, 1996).A fundamental conviction behind this paper is

that words and ideas matter. It matters that wespeak a language of need in terms of moral econ-

omy and interdependence, rather than in terms ofmoral nihilism and radical individualism. Wordsmatter because ``what we cannot imagine and

express in language has little chance of becoming asociological reality'' (Bellah et al., 1985, p. 15).And, further, as Glendon says: ``The way we name

things and discuss them shapes our feelings, judg-ments, choices and actions, including politicalactions'' (Glendon, 1991, p. 11).Ideas are powerful because, as Stone says (Stone,

1988, p. 7):

... the essence of policy making in political communities[is] the struggle over ideas. Ideas are a medium ofexchange and a mode of in¯uence even more powerfulthan money and votes and guns. Shared meanings motiv-ate people to action and meld individual striving into col-lective action.

Ideas matter, too, because ``our strongest bul-wark against demagoguery is the habit of criticaldiscussion about and self-conscious awareness of

the public ideas that envelop us'' (Reich, 1988, p.10). The language and ideas of the market, corpor-atism and globalization currently dominate public

discourse. It is public health, in part through redis-covering and rearticulating its moral underpinningsin a language of need, that provides a possiblecountervailing discourse.

AcknowledgementsÐThe author gratefully acknowledgesthe insightful and very helpful comments of MeredithMinkler and of anonymous reviewers on earlier versionsof this paper.

*Polis is used here, similar to its classical Greek useage(Stone, 1988), to refer to the entire domain of publicdiscourse. This is di�erent from the more narrow senseof ``political'' characteristic of a Rawlsian liberalism,which ``entails a narrow focus on state governmentand the enforcement of laws'' (Frazer and Lacey, 1995:p. 235). According to Nancy Fraser, ``something is''political`` if it is contested across a range of di�erentdiscursive arenas and among a range of di�erent pub-lics'' (Fraser, 1990, p. 165).

A. M. Robertson1428

REFERENCES

Abel-Smith, B. and Titmuss, K. (ed.) (1987) ThePhilosophy of Welfare: Selected Writings of RichardTitmuss. Allen and Unwin, London.

Alinsky, S. (1972) Rules for Radicals. Random House,New York.

Ashton, J. (ed.) (1993) Healthy Cities. Open UniversityPress, Bristol.

Beattie, A. (1986) Community development for health:from theory to practice. Radical Health Promotion 4,12±18.

Beauchamp, D. E. (1976) Public health as social justice.Inquiry 12(1), 3±14.

Beauchamp, D. E. (1983) What is public about publichealth. Health A�airs 2(4), 76±87.

Beauchamp, D. E. (1988) The Health of the Republic:Epidemics, Medicine, and Moralism as Challenges toDemocracy. Temple University Press, Philadelphia.

Bellah, R., Madsen, R., M., S. W., Swidler, A. andTipton, S. M. (1985) Habits of the Heart: Individualismand Commitment in American Life. Harper and Row,New York.

Bellah, R. N., Madsen, R., Sullivan, W. M., Swidler, A.and Tipton, S. M. (1991) The Good Society. Alfred A.Knopf, New York.

Brinkley, A. (1996) Liberty, community and the nationalidea. The American Prospect 29 (November±December),53±59.

Daniels, N. (1985) Just Health Care. CambridgeUniversity Press, Cambridge.

Daniels, N. (1988) Am I My Parents' Keeper. OxfordUniversity Press, Oxford.

Doyal, L. and Gough, I. (1991) A Theory of Human Need.MacMillan, London.

Duhl, L. (1986) The healthy city: its function and itsfuture. Health Promotion 1(2), 55±60.

Dworkin, R. (1977) Taking Rights Seriously. Duckworth,London.

Ellencweig, A. Y. and Yoshpe, R. B. (1984) De®nition ofpublic health. Public Health Review 12, 65±78.

Farrant, W. (1986) ``Health for All'' in the Inner City:Proposed Framework for a Community DevelopmentApproach to Health Promotion Policy and Planning at aDistrict Level. No. Paddington and North KensingtonHealth Authority, London.

Fraser, N. (1990) Talking about needs: interpretive con-tests as political con¯icts in welfare-state societies. InFeminism and Political Theory. ed. C. R. Sunstein.University of Chicago Press, Chicago and London.

Frazer, E. and Lacey, N. (1993) The Politics ofCommunity: A Feminist Critique of the Liberal-Communitarian Debate. University of Torono Press,Toronto.

Frazer, E. and Lacey, N. (1995) Politics and the public inRawls' political liberalism. Political Studies XLIII, 233±247.

Freire, P. (1988) Pedagogy of the Oppressed (MyraBergman Ramos, Trans). Continuum, New York.

Friedman, M. (1993) Beyond care: the de-moralization ofgender. In An Ethic of Care: Feminist andInterdisciplinary Perspectives. ed. M. J. Larrabee.Routledge, New York and London.

Galtang, J. and Wirak, A. (1978) On the Relationshipbetween Human Rights and Human Needs. Con¯ict andPeace and Research, University of Oslo, Oslo.

Glendon, M. A. (1991) Rights Talk: The Impoverishmentof Political Discourse. The Free Press, New York.

Go�man, E. (1963) Stigma: Notes on the Management ofSpoiled Identity. Prentice-Hall, Englewood Cli�s, NJ.

Government of Canada (1986) Ottawa charter for healthpromotion. Health Promotion 1(4), iii±v.

Greeley, A. (1997) The other civic America: religion andsocial capital. The American Prospect 32 (May±June),68±73.

Guest, D. (1980) The Emergence of Social Security inCanada. University of British Columbia Press,Vancouver.

Hahnel, R. and Albert, M. (1990) A Quiet Revolution inWelfare Economics. Princeton University Press,Princeton, NJ.

Health and Welfare Canada (1986) Achieving Health forAll: A Framework for Health Promotion. Government ofCanada, Ottawa.

Heying, C. (1997) Civic elites and corporate delocalization:an alternative explanation for declining civic engage-ment. American Behavioral Scientist 40 (March/April),656±667.

Ignatie�, M. (1984) The Needs of Strangers. PenguinBooks, Harmonsworth.

Illich, I. (1977) Disabling Professions. In DisablingProfessions, ed. I. Illich, I. K. Zola, J. McKnight, J.Caplan and H. Shaiken. Marion Boyars, London.

Kaminer, W. (1997) Unholy alliance. The AmericanProspect 35 (November±December), 54±55.

Kawachi, I., Kennedy, B. P. and Lochner, K. (1997) Longlive community: social capital as public health. TheAmerican Prospect 35, 56±59.

Kickbusch, I. (1989) Approaches to an ecological base forpublic health. Health Promotion 4(4), 265±268.

Kingson, E. R., Hirshorn, B. A. and Cornman, J. M.(1986) Ties That Bind: The Interdependence ofGenerations. Seven Locks Press, Washington, DC.

Kohli, M. (1991) Retirement and the moral economy: anhistorical interpretation of the german case. In CriticalPerspectives on Aging: The Political and Moral Economyof Growing Old. M. Minkler and C. L. Estes. BaywoodPublishing, Amityville, New York.

Labonte, R. (1993) Health Promotion and Empowerment:Practice Frameworks. Centre for Health Promotion/Partcipaction, Toronto.

Lotz, J. (1987) Community Development: A short history.Journal of Community Development (May/June), 41±46.

Lukes, S. (1985) Marxism and Morality. OxfordUniversity Press, Oxford.

MacIntyre, A. (1984) After Virtue: A Study in MoralTheory, 2nd edn. University of Notre Dame Press,Notre Dame, IA.

McKnight, J. (1977) Professionalized service and disablinghelp. In Disabling Professions, ed. I. Illich, I. K. Zola, J.McKnight, J. Caplan and H. Shaiken. Marion Boyars,London.

McKnight, J. (1987) Regenerating community. SocialPolicy Winter, 54±58.

Minkler, M. (1989) Health education, health promotionand the open society: an historical perspective. HealthEducation Quarterly 16(1), 17±30.

Minkler, M. (1990) Improving health through communityorganization. In Helath Behavior and Helath Education:Theory, Research, and Practice, ed. K. Glanz, F. M.Lewis and B. Rimer. Jossey-Bass, Oxford.

Minkler, M. and Cole, T. (1991) Political and moral econ-omy: not such strange bedfellows. In CriticalPerspectives on Aging: The Political and Moral Economyof Growing Old. ed. M. Minkler and C. L. Estes, pp.37±49. Baywood Publishing Co., Amityville, NY.

Montague, P. (1996) Economic inequality and health,Rachel's Environment and Health Weekely 497 (June 6).

Nozick, R. (1974) Anarchy, State, and Utopia. BasicBooks, New York.

Nyswander, D. (1967) The open society: its implicationsfor health educators. Health Education Monographs 1,3±13.

O'Neill, J. (1985) Five Bodies: The Human Shape ofModern Society. Cornell University Press, Ithaca, NY.

Critical re¯ections on the politics of need 1429

Putnam, R. D. (1993a) Making Democracy Work.Princeton University Press, Princeton.

Putnam, R. D. (1993b) The prosperous community: socialcapital and public life. The American Prospect 13(Spring), 35±43.

Putnam, R. D. (1995) Bowling alone: America's decliningsocial capital. Journal of Democracy 6(1), 65±78.

Putnam, R. D. (1996) The strange disappearance of civicAmerica. The American Prospect 24, 34±48.

Rawls, J. (1971) A Theory of Justice. Harvard UniversityPress, Cambridge, MA.

Reich, R. B. (ed.) (1988) The Power of Public Ideas.Ballinger Publishing Co., Cambridge, MA.

Reisman, D. (1977) Richard Titmuss: Welfare and Society.Heinemann, London.

Sandel, M. J. (1982) Liberalism and the Limits of Justice.Cambridge University Press, Cambridge.

Springborg, P. (1981) The Problem of Human Needs andthe Critique of Civilization. George Allen and Unwin,London.

Stone, D. A. (1984) The Disabled State. Temple UniversityPress, PA.

Stone, D. A. (1988) Policy Paradox and Political Reason.Scott, Foresman/Little, Brown College Division,Glenview, Ill.

Szreter, S. (1988) The importance of social intervention inBritain's mortality decline c. 1850±1914: a re-interpret-ation of the role of public health. The Society for theSocial History of Medicine 1(1), 1±41.

Terris, M. (1994) Determinants of health. Journal ofPublic Health Policy 14(2), 5±17.

Tesh, S. (1990) Hidden Arguments: Political Ideology andDisease Prevention Policy. Rutgers University Press,New Brunswick and London.

Thomson, G. (1987) Needs. Routledge and Kegan Paul,London.

Titmuss, R. (1963) The irresponsible society. In Essays on``The Welfare State'', ed. R. Titmuss. George Allen andUnwin, London.

Titmuss, R. M. (1968) Commitment to Welfare. GeorgeAllen and Unwin, London.

Titmuss, R. M. (1973) The Gift Relationship. PenguinBooks, Harmondsworth.

Titmuss, R. M. (1974) Social Policy. George Allen andUnwin, London.

Tronto, J. C. (1993) Moral Boundaries: A PoliticalArgument for an Ethic of Care. Routledge, New Yorkand London.

Walker, A. (1990) The economic ``burden'' of ageing andthe prospect of intergenerational con¯ict. Ageing andSociety 10, 377±396.

Wallerstein, N. (1992) Powerlessness, empowerment andhealth: implications for health promotion programs.American Journal of Health Promotion 6(3), 197±205.

Walzer, M. (1983) Spheres of Justice. Basic Books, NewYork.

WHO (1986) Health promotion: a discussion document onthe concepts and principles. Health Promotion 1(1), 73±76.

Wilkinson, R. G. (1994) The epidemiological transition:from material scarcity to social disadvantage. Daedalus123(4), 61±77.

Wilkinson, R. G. (1996) Unhealthy Societies: The A�ictionof Inequality. Routledge, London.

A. M. Robertson1430