Bioethics increasingly recognizes the impact of discriminatory practices based on social categories such as race, gender, sexual orientation or ability on clinical practice. Accordingly, major bioethics associations have stressed that identifying and countering structural discrimination in clinical ethics consultations is a professional obligation of clinical ethics consultants. Yet, it is still unclear how clinical ethics consultants can fulfill this obligation. More specifically, clinical ethics needs both theoretical tools to analyze and practical strategies to address structural discrimination within clinical ethics consultations. (...) Intersectionality, a concept developed in Black feminist scholarship, is increasingly considered in bioethical theory. It stresses how social structures and practices determine social positions of privilege and disadvantage in multiple, mutually co-constitutive systems of oppression. This article aims to investigate how intersectionality can contribute to addressing structural discrimination in clinical ethics consultations with a particular focus on mental healthcare. To this end, we critically review existing approaches for clinical ethics consultants to address structural racism in clinical ethics consultations and extend them by intersectional considerations. We argue that intersectionality is a suitable tool to address structural discrimination within clinical ethics consultations and show that it can be practically implemented in two complementary ways: 1) as an analytic approach and 2) as a critical practice. (shrink)

Research into epistemic injustice, the practice of discrediting people as knowers based on their social identity, has gained broad popularity in ethics. Racism in medicine often mani...

Liao and Carbonell discuss the role of (supposed) racial differences and racism in two medical devices: pulse oximeters and spirometers. They show that what might seem like cases of mere bias, are...

Events in the US in 2020 have laid bare the reality that racism and its effects continue to take a heavy toll on the lives of Black Americans. The three articles in this issue of AJOB each provide...

“Hypertension in Blacks is a salt disease,” Dr. Anderson1 explained. “Too much salt overloads their renin-angiotensin system and their kidneys can’t handle it. It’s just the way their bodies work....

In “Racism and Bioethics: the myth of color blindness” Braddock convincingly argues that a “color blind” approach to triage and resource allocation in the setting of the COVID-19 pandemic pe...

Bioethicists in healthcare institutions have the skills and insights and can and must facilitate and promote measures that address deeply ingrained structural issues that exacerbate health inequity...

Black women and their babies matter. In this commentary, we explore the current challenges that Black women face when pregnant and what is needed to ensure an anti-racist approach to prenatal and p...

One of the central characteristics of public health disasters is the rapid overlapping of different needs and priorities that require making critical choices that inevitably elicit conflicti...

This paper opens a critical conversation about the ethics of international bioethics conferencing and proposes principles that commit to being anti-discriminatory, global, and inclusive. We launch this conversation in the Section, Case Study, with a case example involving the International Association of Bioethics’ (IAB’s) selection of Qatar to host the 2024 World Congress of Bioethics. IAB’s choice of Qatar sparked controversy. We believe it also may reveal deeper issues of Islamophobia in bioethics. The Section, Principles for International Bioethics Conferencing, sets (...) forth and defends proposed principles for international bioethics conferencing. The Section, Applying Principles to Site Selection applies the proposed principles to the case example. The Section, Applying Principles Beyond Site Selection addresses other applications of the proposed principles. The Section, Objections responds to objections. We close (in the Section, Conclusion) by calling for a wider discussion of our proposed principles.One-Sentence Capsule Summary: How should bioethicists navigate the ethics of global bioethics conferencing? (shrink)

“Ignorance,” Jim Hudson, the art dealer, declares shortly before the climactic scene in the 2017 film, Get Out. “They mean well, but they have no idea what real people will go through”...

Like more than two hundred thousand other Americans, George Floyd howled horribly for air before his death. But his breathlessness was not born from a virus. He was murdered with the burden of anti...

An Artificial Intelligence algorithm trained on data that reflect racial biases may yield racially biased outputs, even if the algorithm on its own is unbiased. For example, algorithms used to schedule medical appointments in the USA predict that Black patients are at a higher risk of no-show than non-Black patients, though technically accurate given existing data that prediction results in Black patients being overwhelmingly scheduled in appointment slots that cause longer wait times than non-Black patients. This perpetuates racial inequity, in (...) this case lesser access to medical care. This gives rise to one type of Accuracy-Fairness trade-off: preserve the efficiency offered by using AI to schedule appointments or discard that efficiency in order to avoid perpetuating ethno-racial disparities. Similar trade-offs arise in a range of AI applications including others in medicine, as well as in education, judicial systems, and public security, among others. This article presents a framework for addressing such trade-offs where Machine Learning and Optimization components of the algorithm are decoupled. Applied to medical appointment scheduling, our framework articulates four approaches intervening in different ways on different components of the algorithm. Each yields specific results, in one case preserving accuracy comparable to the current state-of-the-art while eliminating the disparity. (shrink)

Racial inequities in medicine are the consequence of intersecting, multidimensional factors. As detailed in the articles by Braddock, Mithani, Cooper, and Boyd, and Yearby, the...

There are some long-standing social issues that imperil Black Americans’ relationship with health and healthcare. These issues include racial disparities in health outcomes, provider bi...

The three important target articles make a strong case for regarding racism as a public health crisis. Each calls for advocacy by the bi...

This paper addresses the just distribution of vaccines against the SARS-CoV-2 virus and sets forth an ethical framework that prioritises frontline and essential workers, people at high risk of severe disease or death, and people at high risk of infection. Section I makes the case that vaccine distribution should occur at a global level in order to accelerate development and fair, efficient vaccine allocation. Section II puts forth ethical values to guide vaccine distribution including helping people with the greatest need, (...) reducing health disparity, saving the most lives and promoting narrow social utility. It also responds to objections which claim that earlier years have more value than later years. Section III puts forth a practical ethical framework to aid decision-makers and compares it with alternatives. (shrink)

As the twin pandemics of COVID-19 and state violence against Black Americans dominated our national landscape in the spring of 2020, many in medicine, nursing, and public health made renewed calls...

The three target articles constitute a powerful and persuasive call for actively anti-racist bioethics and biomedicine. All three articles reject race as a biological category. Nevertheless, they share a common commitment to racial classification. At one point, Ruqaiijah Yearby writes that “social race, like biological race, is an illusion created to establish racial hierarchy,” but mostly she writes about “races” as though they were not an illusion, but a reality. In this commentary I critique the racial realism of the target (...) articles. I argue that the biomedical fight against racism is best served by a form of anti-realist reconstructionism about race, which says that there are no races, only racialized groups—groups misunderstood to be races. Note that I do not defend the color blindness that Clarence H. Braddock (2020) persuasively rejects. Because of the role of skin color in racialization and racism, color blindness is a misguided goal. One can reject color blindness, though, without accepting racial realism... (shrink)

BackgroundClinical ethics consultations can be complex interventions, involving multiple methods, stakeholders, and competing ethical values. Despite longstanding calls for rigorous evaluation in the field, progress has been limited. The Medical Research Council proposed guidelines for evaluating the effectiveness of complex interventions. The evaluation of CEC may benefit from application of the MRC framework to advance the transparency and methodological rigor of this field. A first step is to understand the outcomes measured in evaluations of CEC in healthcare settings. ObjectiveThe primary (...) objective of this review was to identify and map the outcomes reported in primary studies of CEC. The secondary objective was to provide a comprehensive overview of CEC structures, processes, and roles to enhance understanding and to inform standardization.MethodsWe searched electronic databases to identify primary studies of CEC involving patients, substitute decision-makers and/or family members, clinicians, healthcare staff and leaders. Outcomes were mapped across five conceptual domains as identified a priori based on our clinical ethics experience and preliminary literature searches and revised based on our emerging interpretation of the data. These domains included personal factors, process factors, clinical factors, quality, and resource factors. ResultsForty-eight studies were included in the review. Studies were highly heterogeneous and varied considerably regarding format and process of ethical intervention, credentials of interventionist, population of study, outcomes reported, and measures employed. In addition, few studies used validated measurement tools. The top three outcome domains that studies reported on were quality, process factors, and clinical factors. The majority of studies examined multiple outcome domains. All five outcome domains were multidimensional and included a variety of subthemes.ConclusionsThis scoping review represents the initial phase of mapping the outcomes reported in primary studies of CEC and identifying gaps in the evidence. The confirmed lack of standardization represents a hindrance to the provision of high quality intervention and CEC scientific progress. Insights gained can inform the development of a core outcome set to standardize outcome measures in CEC evaluation research and enable scientifically rigorous efficacy trials of CEC. (shrink)

In a plenary presentation on structural racism at the 2019 American Society of Bioethics and Humanities Annual Meeting, invited speaker Mary T. Bassett asserted that there is no solidarity without...

In mental health ethics, it is generally assumed that coercive measures are sometimes justified when persons with mental illness endanger themselves or others. Coercive measures are regarded as ethically justified only when certain criteria are fulfilled: for example, the intervention must be proportional in relation to the potential harm. In this paper, we demonstrate shortcomings of this established ethical framework in cases where people with mental illness experience structural racism. By drawing on a case example from mental healthcare, we first (...) demonstrate that biases in assessing whether the coercive intervention is proportional are likely, for example, due to an overestimation of dangerousness. We then show that even if proportionality is assessed correctly, and the specific coercive intervention would thus be regarded as ethically justified according to the standard framework, coercion may still be ethically problematic. This is because the standard framework does not consider how situations in which coercive measures are applied arise. If structural racism causally contributes to such situations, the use of coercion can compound the prior injustice of racist discrimination. We conclude that the ethical analysis of coercion in mental healthcare should consider the possibility of discriminatory biases and practices and systematically take the influence of structural discrimination into account. (shrink)

Zusammenfassung Im internationalen Diskurs sind feministische Perspektiven auf die Medizinethik bereits etabliert. Demgegenüber scheinen diese bislang nur vereinzelt in den deutschsprachigen medizinethischen Diskurs eingebracht zu werden. In diesem Artikel untersuchen wir, welche feministischen Perspektiven im deutschsprachigen medizinethischen Diskurs vertreten sind, und schlagen weitere Ansätze für eine feministische Medizinethik vor. Zu diesem Zweck zeichnen wir mittels einer systematisierten Literaturrecherche feministische Perspektiven im deutschsprachigen medizinethischen Diskurs seit der Etablierung der Medizinethik als eigenständiger institutionalisierter Disziplin nach. Wir analysieren, welche Themen bereits innerhalb der (...) Medizinethik aus einer feministischen Perspektive untersucht worden sind, und identifizieren Leerstellen. Basierend auf der Literaturrecherche, unseren eigenen Vorarbeiten sowie der Zusammenarbeit in der Arbeitsgruppe in der Akademie für Ethik in der Medizin „Feministische Perspektiven in der Bio- und Medizinethik“ stellen wir drei Thesen vor, die aus unserer Sicht einer Weiterentwicklung des deutschsprachigen medizinethischen Diskurses dienen können. Die erste These bezieht sich auf die Ziele feministischer Medizinethiken und besagt, dass diese (epistemische) Gerechtigkeit anstreben. Die zweite These stellt zentrale Eigenschaften von feministischen Medizinethiken als kritisch und kontext-sensibel heraus. In der dritten These diskutieren wir Intersektionalität und Postkolonialismus als theoretische Ansätze, die zu einer epistemisch gerechten, kritischen und kontext-sensiblen Medizinethik beitragen können. Wir argumentieren, dass feministische Perspektiven grundständig verankert werden sollten. Der Artikel schließt mit einem Ausblick auf die Arbeit der im letzten Jahr gegründeten Arbeitsgruppe in der Akademie für Ethik in der Medizin „Feministische Perspektiven in der Bio- und Medizinethik“. (shrink)

Definition of the problemFeminist approaches to medical ethics are well established in international discourses. By contrast, in the German-speaking medical ethical discourse, they still seem to be rather marginal. In this article, we analyze which feminist perspectives are prominent in German medical ethics and suggest new approaches.ArgumentsWe present our results from a systematized review of the literature, in which we identify existing feminist approaches within the German-speaking medical ethics discourse as well as research gaps. Based on the review, our preliminary (...) research and discussions in the working group “Feminist perspectives in bio and medical ethics”, we defend three hypotheses aimed at advancing the German feminist medical ethical discourse. We posit that (1) feminist medical ethics aim at (epistemic) justice, (2) feminist medical ethics are critical and context-sensitive, and (3) intersectional and postcolonial approaches within feminist medical ethics may contribute to epistemically just, critical, and context-sensitive medical ethics.ConclusionWe argue that feminist perspectives should be implemented as a fundamental perspective in medical ethics because they can bring together key dimensions such as epistemically just, critical, context-sensitive, intersectional, and postcolonial thinking. (shrink)

This month the American Journal of Bioethics examines the intersectionality of medicine, ethics, and race. In “Race, Power, and COVID-19: A Call for Advocacy Within Bioethics,” Mithani and colleagu...