A global ethics approach to vulnerability

In exploring the concept of vulnerability, we do not begin with a blank slate. In research involving human subjects, ethics guidelines typically provide a rough definition of the concept. For example, the commentary on Guideline 13 in the International Ethical Guidelines for Biomedical Research Involving Human Subjects, issued by the Council for International Organizations of Medical Sciences (CIOMS), says that "vulnerable persons are those who are relatively (or absolutely) incapable of protecting their own interests. More formally, they may have insufficient power, intelligence, education, resources, strength, or other needed attributes to protect their own interests" (CIOMS 2002). Because the CIOMS guidelines deal with the ethics of research involving human beings, the core idea in the CIOMS approach to vulnerability lies in the voluntariness with which people can decide to enroll in research, withdraw from research, and more generally determine whether being a research subject best serves their own interests.

In the context of clinical care, some of the same considerations that make research subjects vulnerable also apply to patients. The authors of an article on palliative care describe what makes dying patients especially vulnerable:

This is a vulnerable population in a situation complicated by physical decline and often debilitating symptoms of discomfort and distress. The situation is further complicated by the emotional intensity inherent in the knowledge of impending death and the reality of diminishing time.

(Dean and McClement 2002, 376)

The authors also refer to "relational vulnerability," which stems from interactions between caregiver and patient that may cause distress or other problems.

It is a virtual truism that vulnerable individuals and groups stand in need of protection. The best means of protecting patients who lack the full capability to protect their own interests is through the involvement of devoted family members or friends in decisions about treatment and care. In the context of human subjects research, several mechanisms exist to protect the rights and welfare of vulnerable persons: international ethical guidelines address vulnerable persons (CIOMS 2002; UNAIDS/WHO 2007); research ethics committees are charged with prospective reviews of research and can propose additional safeguards for vulnerable individuals or groups; and, as in clinical care, close family members can and should be involved in the process of obtaining informed consent when prospective subjects have diminished capacity.

Public health, gender equity, and social determinants

With bioethics taking a turn to public health ethics in recent years, a different approach to vulnerable groups and individuals is needed. Unlike the settings of clinical care and research, which focus on vulnerable individuals, the context of public health requires an approach to vulnerable groups and a fashioning of remedies applicable to populations rather than individuals. As one article by feminist scholars contends:

Public health, unlike clinical medicine, must be concerned with the well-being of the public—i.e., its concern must extend beyond individuals to communities and to populations. Further, public health ethics, like clinical ethics and research ethics must become more relational and less individualistic.

(Baylis, Kenny, and Sherwin 2008, 198)

The approach to vulnerability in the present article derives from this feminist approach to public health ethics. A segment comprising about 50 percent of the public—women—may be in need of protection in some contexts. Although individual women become sick or injured, the protections needed are for large groups of women in various social and cultural settings.

Two other recent trends, in this case in epidemiology (the study of diseases in populations), inform the approach to vulnerability in this article. One trend is a focus on health disparities among population groups, both within countries and globally; the second is an exploration of social determinants of health. Most studies of health disparities provide clear evidence of better health status and disease outcomes in wealthier populations than those in the lower socioeconomic classes. However, epidemiologists have paid much less attention to disparities between women's and men's health. The authors of one study on gender inequity in health confirm this:

For many who work on or advocate health equity, the sources of inequity are primarily viewed as linked to gender-blind concepts of economic class differentials. Discussion...