Why are questions of social justice so important to the work of bioethics?

Often when one thinks about bioethics, they assume the medical application of bioethics – big questions around emerging technologies in healthcare. While these medical and technological advances are important, they often fail to acknowledge or highlight questions of social justice or human well-being.

I was born into a robust, African American, religious, musical, and intellectual tradition. My uncle, Nelson H. Smith, Jr., was a civil rights leader in Birmingham, Alabama, a pastor for 53 years who worked closely with Martin Luther King, Jr., Fred Shuttlesworth, and many others in the city. I was also influenced by my aunt, Ernestine Motley, who was the first African American to graduate from a formerly segregated college in Alabama after Brown v. Board of Education –Springhill College, a little Jesuit school in Mobile, AL. While I didn’t realize it early on, growing up amid the recent history of these experiences has shaped me personally and professionally. As a lifelong reader and learner himself, my uncle would always remind me that while my academic work was great –– “Just don’t forget about the people.” Throughout my career, I have come to realize that yes, there is theoretical work that has to be undertaken, but not in a manner that is completely detached from the lived experience of human beings. To this end, there are certain questions that captivate my mind in my work, particularly around the social justice implications of bioethics.

My research in health and healthcare disparities, for example, examines the distinctions affecting people based on race and socioeconomic status. It is sobering when we think about the alarming statistics around the claim that a significant indicator of health outcomes is based on zip codes. Among these outcomes are increased incidents of infant mortality, insufficient reproductive healthcare, higher rates of diabetes, hypertension and heart disease, and even the way people die. As I started wrestling with these issues, it became increasingly difficult, if not impossible, to talk about what it means to value life at the end of life for those who are living and dying on the margins without asking the question, “What does it mean to value life before the end of life?”

Questions of social justice are also critical in the world of biomedical ethics. The fact that bioethics brings together so many disciplines makes answering ethical questions both exhilarating and challenging at the same time. In the age of being able to manipulate our own genetic structure – creating physical and psychological changes in our own bodies and in shaping the next generation through emerging biomedical technologies – we must remain engaged in fundamental, philosophical, and theological questions around what it means to be human and what kind of people we aim to be. With new medical and technological advances comes a temptation to select particular human traits and undermine social justice. Are these benign, morally-neutral choices, or are we seeking to avoid those characteristics in others that we deem inferior or flawed? With the latter, we are making troubling statements about people who are living with those kinds of characteristics we choose against, particularly when racialized.

Social justice is also important to the work of bioethics when considering factors of environmental ethics. Through my experiences as an advocate for affordable housing, I know firsthand it is hard to separate health and health outcomes from the larger environment or biosphere in the places where people live and interact. Waste and pollutants are often placed in areas where people are already politically disenfranchised and disempowered. In a class discussion about Flint, Michigan, a student from a wealthy city in Michigan raised her hand and noted of her community, “In 48 hours the wheels would have been moving to fix the problem!” Climate change also disproportionately affects areas with significant populations of underrepresented minorities and economically disenfranchised. These communities are less likely to receive adequate protection to prevent disasters and also less likely to receive immediate response when emergencies occur. Understanding the impact the environment can have on health and health outcomes puts environmental ethics squarely in this conversation.

The future of bioethics must lean into conversations where theology, philosophy, political science, sociology and ethics can help us think about disparities in health and human well-being. Race and class, and other social determinants of health should not be just as an afterthought, but as an emphasis of our work. I think we need a concept of human flourishing that makes clear the implications of health disparities and that can help us identify what makes a health inequality an injustice. In the words of N.H. Smith, Jr., “Don’t forget about the people.” The words of my uncle continue to guide me.

Patrick T. Smith
Associate Research Professor of Theological Ethics and Bioethics – Duke Divinity School
Senior Fellow, Kenan Institute for Ethics, Duke University
Associate Faculty, Trent Center for Bioethics, Humanities, and the History of Medicine, Duke University School of Medicine

Profile

Patrick Smith was in New England for about 10 years before coming to Duke, teaching at Gordon-Conwell Seminary and the Harvard Medical School’s Center for Bioethics. There, he started leaning into issues of social ethics, social justice, and how they tie to issues of bioethics. Initially working in clinical ethics, Smith was the ethics coordinator for a Hospice Care Center in Michigan and served on the Ethics Advisory Council for the National Hospice and Palliative Care Organization. As he continued to wrestle with issues of health care and health care ethics and health outcomes, he recognized that he could not be detached from questions of social ethics – or larger issues of how we live together and the way our social systems and structures, issues of housing, education, transportation, employment and economics. All these aspects of our collective life are wrapped up in particular ways that impact health and health outcomes.

In his conversations about coming to Duke, he began to see it as a place with an interdisciplinary character. He was really excited to work with the Kenan Institute for Ethics, an interdisciplinary hub where he could bring together his work in philosophical ethics and Christian social ethics- along with his work in bioethics and healthcare. With the added incentive of working with another interdisciplinary program, the Theology Medicine, and Culture Initiative at Duke Divinity School, Smith made the decision to move to Duke—one of only three places he and his wife agreed they could leave New England for.