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Posted on January 3, 2022 at 5:33 PM

This editorial appears in the Jan 2022 issue of the American Journal of Bioethics.

Elizabeth P. Clayborne and Marcella Nunez-Smith

As physicians, the supreme importance of health and its integral role in any individual’s pursuit of life, liberty and happiness is exhibited on a daily basis. It is abundantly clear that without health one cannot focus on any other facet of life and therefore health serves as the foundation on which wellness is grounded. It has also become clear that social determinants of health have a significant influence on health status and remain paradoxically the most malleable and yet the most challenging paradigm through which we can improve the lives of human beings. This clarity, importantly, has only crystallized because of recent strides in public health and medical research examining, characterizing and linking health outcomes to multiple social factors including racism (Williams, Lawrence, and Davis 2019). Without this data and published research on health disparities, many of the sequela of racism in the United States would remain underreported, denied and downplayed.

We find it interesting that the field of bioethics has failed to be an early adopter and leader in addressing inequities and social justice issues given its roots in the study of biology, ecology, medicine, and human values (Goldim 2009). To the contrary, bioethics has struggled to respond to institutional racism because, similar to medicine, it is founded in a history of whiteness (Danis, Wilson, and White 2016). Fabi and Goldberg (2022) have poignantly raised important questions regarding funding priorities in bioethics research and how this perpetuates injustice. We argue that while organized medicine still has significant shortcomings in addressing health inequities, it has provided some practical approaches to addressing social justice that can be adopted and modeled in bioethics. The most effective of which is increasing the number of black and minority members and outlining clear paths to leadership and influence in the field.

As defined by the Centers for Disease Control and Prevention, social determinants of health (SDOH) are conditions in the places where people live, learn, work, and play that affect a wide range of health and quality outcomes. The United States government began investigating healthcare disparities and increased mortality in minoritized groups in the Heckler Report of 1985 (Heckler 1985). Healthcare disparities continue today and range from cardiac and cancer care, neonatal and obstetric mortality, access to healthcare and most recently admission rates and mortality associated with the COVID-19 pandemic (CDC, “COVID-19 Racial and Ethnic Health Disparities” 2020). Health disparities existed long before research began to document the details linking SDOH and health metrics but it was only after this data became widely available and discussed in organized medicine that demands for change were acknowledged and addressed. For decades, organized medicine was restricted to the limited and biased membership of white men who dominated its positions of leadership and left little room for the participation, perspective or influence of women or people of color. This laid a foundation in medicine that operated from a center with whiteness as the norm. To decenter whiteness, we must hold our professional and educational institutions accountable and encourage a multipronged approach in which social justice is pursued through broadening research, understanding bias and increasing diversity.

Fabi and Goldberg (2022) argue that a central facet of this approach will require allocation of funding streams in bioethics to support scholarship, research, and training to address social determinants of health and population level bioethics. It is true both in practical life as well as academics one must “put one’s money where one’s mouth is.” It is not enough to proclaim that social justice is important and that health inequities should be addressed. Bioethics must back up this movement with real dollars and real accountability. While organized medicine is still largely white and male, educational institutions and professional organizations have made strides in diversifying its membership and leadership. Much of this progress was obtained through purposeful, specific and quota based programs. For example, success in pipeline programs for underrepresented minorities (URMs) in emergency medicine focused on early educational interventions, community outreach, creating diversity committees, including URMs in positions of leadership, and expanding recruitment targets to include “added values” that URMs can bring to a residency or department (Clayborne et al. 2021). They also specifically cited that stopping affirmative action initiatives can threaten these pipeline programs and the ability to produce URM physicians who are more likely to serve in underserved communities and work to reduce health disparities. ​​Affirmative action programs are proactive and have been necessary to counter the often invisible and under-acknowledged reality of “legacy action” which selectively advantages some and disadvantages others. Programs that have successfully increased diversity in organized medicine have silenced the myth of meritocracy that is often used as a counterpoint in narratives that claim increasing representation somehow compromises excellence. To the contrary, improved education, clinical outcomes and quality measures have been associated with increased diversity (Clayborne et al. 2021).

In order to produce change in bioethics, similar aggressive measures will be necessary to transform the face of the field that too long has operated as a club with limited diversity and rampant bias. As a field that prides itself on moral discourse, balance and fairness, we feel that initiatives that seek to improve social justice issues are long overdue in bioethics. Research on social determinants of health and population based bioethics is essential to combat epistemic injustice in both forms as testimonial prejudice and hermeneutical injustice. Funding this research is an essential element to substantiating change and the path to improving these funding aims could be modeled after similar practices in organized medicine that have garnered success through a focus on increasing the number of minorities in research and leadership.

To be clear, we are not arguing that organized medicine is the ideal or has even come close to repairing the hundreds of years of atrocities that it has inflicted on marginalized and minoritized groups. Even today, much of the tradition, educational structure and membership of organized medicine propagates a myriad of health inequities and there is much work to be done. Still, bioethics can learn from where organized medicine has made some strides. This includes specific accountability measures that increase the number of black and brown researchers and propels them into real leadership positions. More diversity at the top of bioethics will enable the flow of necessary dollars that support research addressing social justice issues. In turn, this will also address the erasure of black excellence and combat the marginalization of the research inquiry in minoritized groups. History will judge bioethics, there is still time to make a change and put our money where our mouth is.

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