01. Blake & Brock.indd Justice, Fairness, and the Brain Drain M ICH A E L BL A K E University of Washington GI L L I A N BROCK University of Auckland ABstRACt The emigration of skilled professionals from developing societies to more wealthy ones has troubling ethical implications. This form of emigration may undermine the efforts of developing countries to build robust political institutions, as those who leave are those most able to demand institutional change and reform in government. Such emigration also represents a regressive transfer of wealth, as those educated by an impoverished society frequently use that education to benefit the more well-off. Gillian Brock and Michael Blake agree that this phenomenon deserves moral attention, but disagree about what states of origin might legitimately do in response. Brock argues that the state has some right to condition exit upon the performance of some specified term of public service; Blake, in contrast, argues that liberalism demands robust rights of exit, even when that exit does not tend to move the world towards global justice. This overview examines their respective arguments, as well as their shared assumptions about both liberal theory and empirical fact. Keywords: emigration, justice, international law, freedom. INTRODUCTION We tend to think that at least some forms of inequality are wrong – are, indeed, unjust. To fully explain why, though, we have to describe at least three features of the inequality in question. The first is the what of inequality: what is that thing whose distribution is to be taken as morally pernicious? What is it, to use the language of an earlier debate, that is the 84 Michael Blake & Gillian Brock LEAP 4 (2016) currency of justice in this context? The second question is the why of inequality: why is this particular form of inequality to be taken as morally problematic? Not all cases of inequality are worthy of being regarded as unjust; why should this one be so viewed? The final question is the how of justice. Given that we now know what the inequality is, and why it is unjust, what is there to be done about that injustice? Not all proposed policy solutions, after all, are both effective and permissible; what is the range of rightful solutions to this existing injustice? In Debating Brain Drain: May States Restrict Emigration? Gillian Brock and Michael Blake focus on a particular sort of inequality, and ask both why that inequality might be unjust, and how that injustice might be legitimately addressed. The inequality in question involves the emigration of highly-skilled (and highly-educated) people from developing countries to wealthy countries —a phenomenon generally referred to as the brain drain. The facts of the brain drain are startling. Look, for example, at the contrast between Japan and Malawi. Japan has around twenty-one physicians per 10,000 people, while Malawi has only one physician for every fifty thousand people.1 This radical inequality in medical skills and talents has, obviously, bad consequences for health; people born in Malawi will live, on average, 32 years fewer than their counterparts born in Japan.2 This inequality, moreover, does not emerge simply because the Malawian government is disinterested in medical education; indeed, many developing societies spend a significant portion of their budgets on training a new generation of medical personnel. The difficulty is that such medical training makes those people desirable on the global market for talent, and many of those trained simply leave the developing world for the developed one. Thus, in 2000, Ghana trained 250 new nurses —and lost 500 nurses to emigration (Awases et al. 2004). In 2001, Zimbabwe graduated 40 pharmacists— and lost 60 (Katere and Matowe 2003). In 2002 alone, Malawi lost 75 nurses to the United Kingdom —a cohort that represented 12% of all the nurses resident in Malawi (Ross et al. 2005: 260). The result has been a continued shortage of medical personnel in developing countries, especially in sub-Saharan Africa, despite considerable investment. It is tempting to conclude that —as a recent editorial put it— America is stealing the world’s doctors (McAllester 2012). Brock and Blake take this sort of inequality as – at the very least – morally troubling. They have a common vision of the what of this particular 1 The data are from studies between 2005 and 2012; they are available at http://kff. org/global-indicator/physicians/. 2 Figures are from 2012 life expectancy data, available at http://cia.gov/library/ publications/the-world-factbook. Justice, Fairness, and the Brain Drain 85 LEAP 4 (2016) inequality. The book is, however, a sustained disagreement about the why and the how. The book is not intended primarily as an empirical study – although the empirical facts are, of course, enormously relevant to the policy conclusions that ought to be adopted. The book is, instead, an argument between philosophers who are committed to the idea of global justice, about why the brain drain is troubling, and what might be legitimately done to counteract the injustice it represents. Our focus includes an inquiry into what might be done at the global level, and by wealthy states, to counteract the brain drain. Our primary inquiry, however, is on the most vexed question of all: may developing states, in the name of justice, prevent or delay the emigration of skilled professionals —or does the right to exit make such policies morally illegitimate? Brock argues, in her portion of the book, that the unregulated emigration of skilled professionals —including, but not limited to, medical personnel— can represent a significant form of injustice. The injustice may involve the frustration of the legitimate expectations of the fellow citizens of the would-be emigrants; they have spent money, which the developing society does not have in abundance, to educate a medical student, only to have the benefits from that investment go to those already well situated. The effects of such emigration may also undermine those institutions that are necessary for the administration of justice. Development as a f lourishing society, that is, requires the creation and maintenance of political institutions, and these institutions are most likely to be sustained by educated and active citizens —exactly that group of citizens whose departure from the developing society is in question. In view of considerations like these, Brock argues that it would be legitimate for many states to engage in policies designed to delay emigration of these professionals, either through some form of conditional repayment scheme or, under certain circumstances, through a temporary restriction of emigration itself. There are, of course, limits here; Brock’s conclusions apply only to states that are poor, but sufficiently responsible and legitimate —and the amount of time owed by the would-be emigrant cannot include more than a few years. Nonetheless, Brock argues that the developing state is within its right to condition the exit of the would-be emigrant, and that such states may end up finding these policies both justified and effective. Blake, in contrast, regards these policies as likely ineffective, and usually unjust. He accepts that the brain drain represents a problematic form of inequality —but that there are some inequalities that could not be eliminated except through means that are, themselves, morally prohibited; these are cases, he argues, of moral tragedy, in which we cannot hope to arrive at a just world through just means. He argues, in particular, that the 86 Michael Blake & Gillian Brock LEAP 4 (2016) polices imagined by Brock are generally unfair, in that they force the burden of making the world just onto a particular subset of the world’s population that had comparatively little role in making that world unjust. These policies, moreover, are likely ineffective given the ways in which restrictions on emigration can sometimes lead to reduced demand for educational services. Most centrally, though, Blake argues that these policies are illiberal. The just state has a right to govern over those people who are within its territorial borders; it has no comparable right to insist upon those people’s continued presence within those borders. This right is defensible with reference to political history, but also with reference to the question of political justification; no justification can be given to the one prevented from leaving that that citizen is bound to accept as morally motivating. Blake concludes that the range of acceptable policy options for those trying to overcome the brain drain is comparatively small. Both Brock and Blake, then, accept that the brain drain is morally disquieting, but disagree about how that disquiet is to be understood – and how it is that we might respond to the circumstances of the brain drain. They agree, however, that sustained inquiry into the brain drain would be of benefit to the world as a whole, and are gratified that the current exchange might help that sustained inquiry begin. BIBLIOGRAPHY Awases, M., A. Gbary, J. Nyoni and R. Chatora, 2004: Migration of Health Professionals in Africa: A Synthesis Report, Brazzaville: World Health Organization. Katere D. R. and L. Matowe, 2003: “Effect of Pharmacist Emigration on Pharmaceutical Services in Southern Africa”, American Journal of Health- System Pharmacy 60: 1169-1170. McAllester, M., 2012: “America Is Stealing the World’s Doctors”, The New York Times (March 7, 2012). Ross S. J., D. Polsky and J. Sochalski, 2005: “Nursing Shortages and International Nurse Migration”, International Nursing Review 52: 253-262.