What Is Social and Global Justice to Bioethics or Bioethics to Social and Global Justice?

What's Hecuba to him, or he to Hecuba, that he should weep for her?

(Hamlet, II, ii)

Justice has always been a value woven tightly into the bioethics agenda. Yet bioethics is also a pragmatic discipline. It has self-consciously cultivated methods of moral reflection that try to generate reasons for action without recapitulating longstanding theoretical divisions. It has also sought to facilitate change through direct engagement with the health care and research institutions most directly influencing relevant ethical issues. Although this blend of reflective engagement has been very successful, it has also generated an almost principled aversion to more institutionally diffuse or more philosophically foundational issues of social and distributive justice.

In "Equity and Population Health: Toward a Broader Bioethics Agenda," Norman Daniels lays out an ambitious plan for expanding and deepening bioethics' engagement with some far-reaching issues of social and distributive justice. He notes the growing empirical evidence that racial, economic, and other disparities among social groups can have a bad effect on the health of people in the most disadvantaged groups, even when they have access to health care services. He then challenges bioethics to dedicate more time and energy to working out what the proper response to such inequalities should be from the standpoint of population health. He also prompts the field to focus more intently on the issue of intergenerational equity, which will only become more acute, especially in the developing world, with the aging of the world's population. Finally, he asks that bioethics devote more energy to questions about when inequalities between communities are unjust, what those of us in wealthy countries owe to the most burdened communities in the developing world, and the proper mechanisms to rectify these inequalities.

This is an important agenda for bioethics. Here I simply want to note three respects in which it poses fundamental challenges to the discipline. First, bringing about social change in these areas will require bioethics to move outside of its familiar institutional bulwarks and engage a range of social and political institutions that are not traditionally associated with health care or scientific research. For example, if the social determinants of health have a profound influence on individual and community health, and if the policies of the International Monetary Fund and the World Bank play a crucial role in influencing the distribution of some of those determinants in the developing world, then bioethicists must become more engaged with these global institutions.

Second, bioethicists must become proficient in some highly technical academic disciplines. In particular, the field will have to deepen its engagement with economics, not only at the level of application, but at the level of first principles. A recurring theme of Daniels's paper is the importance of either modifying or rethinking the framework of cost-benefit analysis (CBA) so that it will more robustly respond to issues of distribution and equity. Mathematically, alternative ways of comparing sets of benefits and their associated costs exist that are sensitive to important thresholds and give greater weight to benefits accruing to those who are worse off without making implausibly strong assumptions (common to most forms of CBA) about the commensurability of value. Although such models have been used in highly technical areas of finance, their implications for ethics and political philosophy remain almost entirely unexplored. In order to motivate their use in a broader policy context, bioethicists will need to understand their implications and demonstrate their relevance to issues of equity. If bioethicists cannot mount such a foundational engagement with the conceptual frameworks and analytical tools that are the stock and trade of global economic institutions, their ability to influence the analyses and decisions shaping the social and economic determinants of population health will likely remain limited.

Finally, this agenda is rife with philosophical questions that sit squarely at the theoretical fault lines dividing competing philosophical traditions and animating partisan political movements. Here I suspect that the field's traditional emphasis on consensus will have to give way to a methodological orientation emphasizing action and policy in the face of unresolved social conflict. In...