Keisha Ray

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.

An argument in the cognitive enhancement literature is that using stimulants in populations of healthy but socially disadvantaged individuals mistakenly attributes pathology to nonpathological individuals who experience social inequalities. As the argument goes, using stimulants as cognitive-enhancing drugs to solve the social problem of poorly educated students in inadequate schools misattributes the problem as an individual medical problem, when it is really a collective sociopolitical problem. I challenge this argument on the grounds that not all types of enhancement have to be explained in medical terms, but rather at least one conception of enhancement can be explained in social terms—opportunity maintenance. Therefore, I propose that as a moral requirement we ought to explore whether stimulants could be a means of remedying underprivileged children's experiences of social inequalities that are borne from inadequate schools for the sake of increasing their chances for opportunities and well-being.

An argument in the cognitive enhancement literature is that using stimulants in populations of healthy but socially disadvantaged individuals mistakenly attributes pathology to nonpathological individuals who experience social inequalities. As the argument goes, using stimulants as cognitive-enhancing drugs to solve the social problem of poorly educated students in inadequate schools misattributes the problem as an individual medical problem, when it is really a collective sociopolitical problem. I challenge this argument on the grounds that not all types of enhancement have to be explained in medical terms, but rather at least one conception of enhancement can be explained in social terms—opportunity maintenance. Therefore, I propose that as a moral requirement we ought to explore whether stimulants could be a means of remedying underprivileged children's experiences of social inequalities that are borne from inadequate schools for the sake of increasing their chances for opportunities and well-being.

Some proponents of moral bioenhancement propose that people should utilize biomedical practices to enhance the faculties and traits that are associated with moral agency, such as empathy and a sense of justice. The hope is that doing so will improve our ability to meet the moral challenges that have emerged in our contemporary, globalized world. In this paper, we caution against this view by arguing that biomedically inducing more empathy may, in fact, diminish moral agency. We argue that this type of increase in empathy would not be effective for addressing empathy’s vulnerability to the biases that can undermine moral judgment. Furthermore, doing so may undermine the important capacity to regulate empathy. We determine that if the moral enhancement project is to be a serious one, it must address these challenges.

Torben Kjærsgaard’s argues that the term “cognitive enhancement substances” is an inappropriate term considering that stimulants do not enhance cognition, but rather only enhance motivation. Therefore, he concludes that stimulants are best described as “performance maintenance” and not “performance enhancement.” I challenge his conclusion on the grounds that both life’s ordinary, daily activities and life’s extraordinary activities are types of performances necessary for living the kinds of lives that we want to live, which can be enhanced, not just maintained, with the effects of cognitive enhancing substances. “Cognitive enhancing substances” may be a misleading term, but referring to the effects of cognitive enhancing substances as “performance maintenance,” rather than “performance enhancing,” misguidedly minimizes the role that motivation plays into our self-determined lives.