Keisha Ray

Le sens de la justice de la bioéthique se manifeste souvent sous la forme de ce que l’on appelle désormais les valeurs d’équité, de diversité et d’inclusion (EDI). À mesure que les programmes et initiatives EDI se multiplient, de nombreux bioéthiciens se voient conseiller, sous diverses formes, de « ne pas parler de EDI et de se contenter de faire leur travail ». Lorsque les bioéthiciens sont invités à abandonner ou à « modérer » leur position sur l’EDI, plusieurs conséquences s’ensuivent : 1) notre travail consistant à remettre en question et à interroger la moralité de nos actions collectives et individuelles et à encourager les autres à faire de même est ignoré; 2) notre identité professionnelle et nos valeurs sont réécrites et utilisées contre nous; et 3) nos identités sociales en dehors de notre pratique de bioéthiciens sont ignorées; cependant, il n’y a pas de bioéthique sans du travail EDI.

Bioethics’ sense of justice often manifests itself as what has become known as diversity, equity, and inclusion (DEI) values. As more DEI programs and initiatives are targeted, many bioethicists are being told some variation of “keep quiet about DEI and just do your job.” When bioethicists are told to abandon or “tone down” DEI a few things follow: 1) our job of challenging and questioning the morality of our collective and individual actions and encouraging others to do the same is ignored; 2) our professional identity and values are rewritten and weaponized against us; and 3) our socially situated identities outside our practice as bioethicists are disregarded; however, there is no bioethics without DEI work.

The current revival of interest in classic psychedelics and other psychoactives such as ketamine and MDMA, coupled with changes to their regulatory status in many jurisdictions, necessitates rigorous ethical guidelines both within and beyond clinical and scientific contexts. This paper examines crucial ethical, philosophical, and policy considerations needed to ensure psychedelic use across various settings remains equitable, beneficial, consensual, and safe, with appropriate accountability mechanisms for addressing potential harms. We seek to broaden the lens beyond the medical model of psychedelics to include potentially valuable non-medical applications that could benefit individuals, communities, and society. With popular interest in psychedelics growing outside of therapeutic and research settings, there is a need to determine which aspects of any proffered guidelines, or underlying principles, should be applied similarly across contexts and in what ways there should be flexibility and/or context-sensitivity in their interpretation or application. In developing such guidelines, we suggest the “treatment versus enhancement” distinction – and associated debates familiar from bioethics and philosophy of medicine – requires renewed attention. We argue that neglecting non-medical and broad scientific use cases for psychedelics may have important implications for a range of ethical issues surrounding psychedelic use and research, including concerns about psychedelic hype and exceptionalism (both positive and negative), therapeutic touch, informed consent, data-gathering, and balancing access and safety. We conclude with suggestions for future directions in research and policy in the burgeoning area of psychedelic bioethics, stressing the importance of incorporating the perspectives of a diversity of stakeholders and fostering cross-sector collaboration.

Using the example of Black people’s inequitable COVID-19 outcomes and their health outcomes prior to the pandemic, I argue that the pandemic has forever changed how we should think about the conceptual and practical nature of health equity. From here on, we can no longer think of health equity without the concept of intersectionality. In particular, we must acknowledge that discrimination (e.g. sexism, ableism, racism, classism, etc.) within our social institutions intersect to withhold resources needed for health from people who themselves have intersecting identities that make them vulnerable to the effects of discrimination. To ignore intersectionality in our work on health equity would mean ignoring a great injustice imposed on some of the most overlooked people in our communities, which would also be a great disserve to bioethics’ professional longevity.

Environmental health remains a niche topic in bioethics, despite being a prominent social determinant of health. In this paper we argue that if bioethicists are to take the project of health justice as a serious one, then we have to address environmental injustices and the threats they pose to our bioethics principles, health equity, and clinical care. To do this, we lay out three arguments supporting prioritizing environmental health in bioethics based on bioethics principles including a commitment to vulnerable populations and justice. We also highlight and advocate for environmental law efforts that align with these priorities, focusing specifically on the need for a right to a healthy environment. Our intention is to draw attention to the legal and ethical concepts that underlie the importance of a healthy environment, and urge bioethicists to prioritize both legal and ethical advocacy against environmental injustices in their practice.

Why do American Black people generally have worse health than American White people? To answer this question, “Black Health” dispels any notion that Black people have inferior bodies that are inherently susceptible to disease. This is simply false racial science that has been used to abuse Black people since our African ancestors were brought to America on slave ships. A genuine investigation into the status of Black people’s health requires us to acknowledge that race has always been a powerful social category. Race largely predetermines individuals’ social and political power and access to resources needed for health and wellbeing. And as a group, Black people have been intentionally denied this power and access. Systemic racism, oppression, and White supremacy in American institutions have largely been the perpetrators of differing social power and access to resources for Black people. It is these systemic inequities that create the social conditions needed for poor health outcomes for Black people to persist. An examination of social inequities reveals that it is no accident that Black people have poorer health than White people, instead in America, almost every institution has been designed to withhold what Black people need for proper health and wellbeing. Black Health provides a succinct discussion of Black people’s health, including the social, political, and at times cultural determinants of their health. This book examines the ways that Black people’s multiple identities—social, cultural, and political—intersect with anti-Black institutions, such as housing and health care to determine their poor outcomes in pregnancy, pain management, sleep, and cardiovascular disease.

Poor health is not inherently a part of Black Americans’ bodies; poor health is not in our DNA. But as Linda Villarosa says in Under the Skin “something about being Black has led to the documented poor health of Black Americans.”1 Like many other scholars of Black health have said, Villarosa proposes, and evidence supports, that “the something is racism.”2 Villarosa attributes Black people’s generally inferior health outcomes in areas like pregnancy and birth, pain care, and cardiology to racism and not a lack of social resources such as money, education, and access to healthcare. Although not always explicitly stated in her text, the stories Villarosa uses to illustrate racism’s effects on health also demonstrate racism’s influence on who has access to the social resources that are needed to maintain health and treat illnesses. Villarosa is right that more education and more income cannot de facto give Black people better health. At the same time, we cannot ignore that although racism is the force, education, money, housing, and access to healthcare are the means by which racism adversely affects health. Education and other social goods only fail to confer better health to Black people because racism serves as a roadblock.

Black people experience lower quality and lesser quantity of sleep than white people. Researchers, however, do not believe that racial disparities in sleep sufficiency are caused by biological differences, but rather by various social differences, such as differences in sleeping environments and socioeconomic status. Racial disparities in sleep sufficiency are a matter of social justice because sleep is important to mental and physical health, meaning racial disparities in sleep sufficiency can contribute to unequal and unjust disparities in overall health. Racial disparities in sleep may also be linked to other racial disparities in health that black people disproportionately experience such as hypertension and obesity. Sleep hygiene, common therapeutic advice given to help induce sleep, is often the first step to helping people sleep. Sleep hygiene, however, does not address the social, legal, cultural, and economic causes of racial disparities in sleep sufficiency. Sleep hygiene, as an ideal theory, addresses sleeplessness under ideal circumstances, only which a small group of privileged people live. Sleep hygiene ignores the unequal circumstances that contribute to some black people’s sleeplessness. Nonideal theory, however, acknowledges the less than ideal circumstances of certain groups, including people of color, and gives us a framework to develop solutions to racial disparities in sleep sufficiency.

Facilities that emit hazardous toxins, such as toxic landfills, oil refineries, and chemical plants, are disproportionately located in predominantly Black, Latinx, and Indigenous neighborhoods. Environmental injustices like these threaten just distribution of health itself, including access to health that is not dependent on having the right skin color, living in the right neighborhood, or making the right amount of money. Facilities that emit environmental toxins wrongly make people's race, ethnicity, income, and neighborhood essential to who is allowed to breathe clean air and drink clean water, and thus, who is allowed to be healthy. This can be seen in the environmental crises in Louisiana; Mississippi; Houston, Texas; and Flint, Michigan. Since bioethics purports to concern itself with the principle of justice as applied to individuals and increasingly to populations, the field ought to concern itself more with environmental injustice.

When health professions learners’ primary pedagogical experience of Black people and how they become patients is through statistics, it becomes very easy for learners to think of Black people as data points rather than as individuals whose health is often at the mercy of racist institutions. When the human dimension of Black people’s health is ignored, specifically the ways that poor health affects individual wellbeing, one of the barriers to proper health for Black patients is how to be seen and considered as a part of a larger problem of systemic racism and institutional injustices as well as individuals whose personal lives are affected by such larger problems. I propose an approach to health professions pedagogy—the experiential race testimonies approach—that can change the way health professions learners understand and treat Black patients, thus changing the future of Black health. The ERT approach pairs population data analysis with analysis of personal testimonies and the experiences they convey.