Global health ethics frameworks, embedded ethics and new approaches to vulnerability
Bridget Pratt (Vice Chair) and Sassy Molyneux (Co-Chair), Ethics of Health Systems Research TWG
We recently attended the 2017 Oxford Global Health and Bioethics International Conference, aimed at promoting multidisciplinary and inclusive discussion of critically important ethical issues in global health. We were excited about several issues pertinent to Health Policy and Systems Research (HPSR) ethics discussed during this excellent meeting.
The importance of health system strengthening
Devi Sridhar in her talk ‘Governing Global Health: Who Runs the World and Why?’ emphasised that power in global health governance lies with three main actors—the US, UK, and the Gates Foundation. Several high profile attendees commented on the distinction between technology or disease-focused versus systems-focused approaches, and asked how donors can be incentivized to be more systems-focused. They also raised concerns about “reverse priorities” where health systems are a central focus in high income countries (e.g. Obamacare and NHS), but relatively neglected for lower and middle income countries (LMICs). Power, politics and equity were thereby raised as critical ethical issues in global health; issues that were also central concerns in the 2016 health systems global meeting.
Ethics on the horizon
Jeffrey Kahn included health systems research ethics in his list of priorities. He also had two suggestions that we think are especially relevant for the emerging field of HPSR ethics.
That global bioethics should make far greater use of existing global health ethics frameworks such as Benatar, Daar, and Singer’s that emphasize values such as solidarity, equity, democracy, and sustainability. We agree, and have regularly referenced this framework in our own HPSR materials.
Ethicists should practice more “embedded ethics”. Reflecting on this, we understand embedded ethics could come in a variety of forms. For example, Bridget Pratt is an ethicist co-located within an ethics institute and a global health institute, and Sassy Molyneux is a social scientist studying ethics issues as part of several multi-disciplinary research projects and on behalf of the institution she is part of.
Doing embedded ethics and social science
Being a co-located ethicist or social scientist can be invaluable in ensuring there is regular, open and honest dialogue and deeper learning between ethicists and health policy and systems researchers. Ethics issues can potentially be identified and responded to more efficiently and effectively. However, there are potential challenges: ethicists’ focuses may be shaped by the research they are linked to, and they may lose objectivity and the ability to be critical of the studies or institutions they are part of. We have already begun to reflect on some of our own work, and would value ideas and experiences from others.
Vulnerability and intersectionality
The meeting closed with keynote presentations given by three inspiring women - Ruth Macklin, Florencia Luna and Maureen Kelley.
Maureen Kelley gave a rich example of an international collaboration conducting diverse forms of embedded ethics research. That research aims to feed into policy and practice and conceptual thinking on a hotly debated topic in bioethics: vulnerability. The collaboration takes forwards conceptual work by Luna and others who argue that vulnerability should be understood as a layered concept rather than a label given to sub-populations. We were struck in Luna’s presentation with overlaps in her conceptualisation of vulnerability with the intersectionality analysis in other fields and with concepts of systematic and corrosive disadvantage from philosophy.
Moving forwards, we are excited to see how Luna and others’ ideas on vulnerability and disadvantage might feed into our intersectional analyses in Research in Gender and Ethics (RinGs), and consider whether this lens could enrich our reflections on embedded ethics, vulnerability, resilience and empowerment.
Watch this space (or, ideally, fill it!)…