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Addressing Structural Injustice: A Call to Action for Bioethics

Tremendous wealth beside abject poverty, a widening income gap, the vast disparity between the life prospects of a black child and a white child — structural injustices are pervasive in our country and many places in the world. What does bioethics have to say about these problems?

The Hastings Center has committed to intensifying it efforts to address structural injustices. Ideas for doing so emerged in a plenary session organized by Hastings last month at the annual meeting of the American Society for Bioethics and Humanities.

Mary Bassett, former Commissioner of Public Health for the City of New York and currently the director of the Center for Health and Human Rights at the Harvard T.H. Chan School of Public Health, began by discussing structural racism as one of the drivers of injustice. Structural racism “refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing inequitable systems that in turn reinforce discriminatory beliefs, values, and distribution of resources, which together affect the risk of adverse health outcomes,” she said. Examples of structural racism include residential segregation, inferior health care quality and access, and mass incarceration, which adversely affects the social determinants of health.

Uprooting racism, Bassett said, requires data followed by action. Attending to the context that gives rise to disparities in risk factors and disease is the starting point of addressing structural racism and other kinds of injustice.

In her remarks at the plenary, Hastings Center president Mildred Solomon said that justice has always been a canonical principle for the field, but “too often, we bioethicists tend to focus only on distributional justice, wanting for example, to ensure fair access to technology’s benefits or to protect some groups from bearing disproportionate burdens in a research context. Our field tends to give far less attention to structural injustices that are a function of power differentials, economic disparity, and longstanding discrimination.” Hastings is now placing issues of justice at the front lines of its concern, and Solomon urged the field to move in this direction.

For example, a new project is taking on the issue of population aging. While Hastings has been long recognized for providing ethical guidance for individual treatment decisions near the end of life, this project is very different. It takes a population level look at aging societies, and asks what justice requires of us, as citizens of aging societies. Funded by the Robert W. Wilson Charitable Trust, the project is examining the social determinants of health and well-being, including the ways in which the vast gap in financial means undermines many older Americans’ ability to age in place. Although the “healthy aging” movement might suggest otherwise, many older adults face a long period of frailty, and not all can live in age-supportive communities, neighborhoods, or homes because they cannot afford to and/or do not have the assistance they need. How can planners, policymakers, designers, and citizens make progress on social inequalities among older adults through planning and design? That is one of the questions that this project is addressing.

Panelists Marion Danis and Virginia Brown proposed other paths that bioethics can take for addressing structural injustice.

Danis, head of the Section on Ethics and Health Policy at the National Institutes of Health and a Hastings Center Fellow, urged attendees to help mitigate inequity with teaching, research, training, and ethics consultations. 

Brown, an assistant professor at Dell Medical School at the University of Texas, proposed several practical things that bioethicists can do, and do more of. They should be proactive in hiring scholars of color and mentoring them. They should be also proactive in reading their publications and not only citing them but also discussing them in articles, books, classrooms, and lectures.  

Published on: November 14, 2019
Published in: Bioethics, Global Health, Health and Health Care

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