Bioethics' traditional focus on clinical relationships and exotic technologies has led the field away from population health, health disparities, and issues of justice. The result: a myopic view that misses the institutional context in which clinical relationships operate and can overlook factors that affect health more broadly than do exotic technologies. A broader bioethics agenda would take up unresolved questions about the distribution of health and the development of fair policies that affect health distribution.
In its early decades, bioethics concentrated on problems arising in two important areas: the dyadic, very special relationships that hold between doctors and patients and between researchers and subjects, and Promethean challenges-the powers and responsibilities that come with new knowledge and technologies in medicine and the life sciences, including those that bear on extending and terminating life. The dyadic relationships yield important goods, impose significant risks, are rife with inequalities in power and authority, and yet are bound by complex rights and obligations. They provide a rich field for ethics to explore. The Promethean challenges are the favorites of the media: how god-like can we become in our relations with people, with animals, and with our environment without losing our moral footing? They attract serious inquiries about how to use knowledge and technology responsibly for the individual and collective good. Unfortunately, they also form the frontline trenches for the contemporary culture wars.
Bioethics' focus on the largely noninstitutional examination of these dyadic relations and the emergence of exotic technologies means other important issues concerning population health and its equitable distribution are not addressed (although there are exceptions to this generalization). The doctor-patient relationship and the researcher-subject relationship do have a bearing on population health since medicine and medical research affect the health of individuals [End Page 22] and populations, but by not examining the broader institutional settings and policies that mediate population health, bioethics has sometimes been myopic, not seeing and not addressing the context in which these relationships operate. Similarly, the focus on exotic technologies may blind bioethics to the broader determinants of health and thus to factors that have more bearing on a larger good both domestically and globally.
To motivate a broader bioethics agenda, I shall focus on issues of equity in three areas: (1) health inequalities between different social groups and the policies needed to reduce them, (2) intergenerational equity in the context of rapid societal aging, and (3) international health inequalities and the institutions and policies that have influence on them. Each area has both domestic and international implications.
There are good reasons for pursuing this broader agenda. The agenda aligns bioethics with the goal of more effectively promoting a fundamental good-namely, improved population health, especially for those who enjoy less of it, domestically and internationally. It focuses bioethics on the pursuit of justice. Justice obliges us to pursue fairness in the promotion of health, but policy needs the guidance of ethics in determining what this means. These population issues provide the relevant institutional context in which we should think about the role of new technologies and the dyadic relationships of health care and medical research. However, for bioethics to play this role, it must draw on-and train its practitioners in-a wider range of philosophical skills and social science disciplines.
What Must We Do to Pursue Equity in Health?
Health egalitarians and health maximizers.
I take "health" to mean normal functioning, that is, the absence of pathology, mental or physical.1 This biomedical account of health is clearly narrower than the widely quoted definition offered by the World Health Organization:" Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."2 The WHO conception erroneously expands health to include nearly all of wellbeing, so it can no longer function as a limit notion. People who actually measure population health, such as epidemiologists, concentrate on departures from normal functioning. As we shall see, understanding health as normal functioning is quite compatible with taking a broad view of the determinants of health revealed by the social determinants literature.
This characterization of...