• Ethics

What does justice in global health bioethics require, and how might we achieve it? Two important contributions to this issue of the Journal address theoretical and practical aspects of these questions in different but complementary ways. From their careful analysis of ‘epistemic injustice’ in global health ethics (‘injustice as it applies to knowledge’ which in one way or another puts a person at a disadvantage), Pratt and de Vries1 conclude that to achieve justice, much depends on what is meant by ‘we’ (‘the people designing, conducting and using knowledge from research’) as well as the ‘what’ (‘the overall purpose/goal’) and the ‘where’ (‘the context in which it is undertaken’) of research. At present, they argue, epistemic injustice in bioethics is characterised by ‘coloniality of knowledge’: the ‘silencing of the epistemologies, theories, principles, values, concepts, and experiences of the global South’ is evident, for example, in ‘an ignoring or rejection of the plurality of knowledge’ and the ‘presentation of the works of a few European philosophers as “universal truths”’. ‘Cognitive justice’, by contrast, ‘affirms the epistemological diversity of the world’ and draws ‘attention to inequalities in the knowledge that is valued in today’s world, including emphases on technical and quantitative measures over qualitative measures rooted in lived experiences, and “expert” scientific knowledge over local and indigenous ways of knowing’. In seeking to remedy epistemic injustice in global health ethics, the authors first investigate, with telling examples, (1) ‘who is producing global health knowledge at the individual, institutional, funder, and journal levels’ and where in the global North or South; (2) ‘what theories and concepts are being applied to derive ethics knowledge’ and (3) ‘whose voices are sought, recorded and used to generate ethics knowledge’. They then, for each of these ‘knowledge-producer’, ‘knowledge-applied’ and ‘knowledge-solicited’ ‘layers’ of global health ethics, make a range of often highly practical proposals for achieving greater epistemic justice in each of them.

Pratt and de Vries have issued a significant challenge to all individuals and institutions, including journals such as this, who claim to be concerned with global health ethics, and indeed to bioethics generally: the agenda they have set deserves close attention, and the commentaries on their feature article are generally supportive. One of these however, as de Vries and Pratt acknowledge in their response to the commentaries,2 raises a more knotty conceptual question. Frimpong-Mansoh3 questions the statement by Pratt and de Vries that ‘it is not clear that greater epistemic justice and any transcultural framework of ethical values that emerges would necessarily give rise to universal values and principles’. Frimpong-Mansoh argues, by contrast, that ‘a defense of epistemic justice to make global bioethics… equitable and accommodative to inclusive voices concomitantly requires an endorsement of intercultural ethical framework (with shared values and principles). Else, global bioethics would be left without an ethical root/foundation, given the attempt to liberate and decolonize it from cultural hegemony and imperialism’. Whether ‘the reality of cultural relativism justifies ‘the validity of ethical relativism’, it might be added, is a critical question today for global bioethics and for global debate on issues as diverse as the war in Ukraine or the religions’ attitudes to same-sex relationships.

In this issue’s extended essay, on global health justice and the distribution of COVID-19 Vaccines,4 Jecker, Atuire, Tindana and Bull critically question the influential ‘idea that vaccine allocation is primarily a negotiation between states’. This idea, they observe, is premised on the view of Western philosophy that nation states are ‘morally free to distribute resources however they see fit unless restitution for an historical injustice is owed’: but during the pandemic, the limits of this approach became clear. Many ‘non-state parties’ also influenced ‘the flow of healthcare resources’; the very scale of the pandemic blurred ‘the distinction between “protecting one’s own” and “protecting people everywhere”; and the ‘statist framework’ was increasingly perceived to be ‘perpetuating global health disparities’. ‘Within bioethics’, moreover, ‘structural injustices’ resulted in a failure ‘to conduct global justice debates in a truly global way – that is, to represent authors and institutions from diverse regions and include concerns pertinent to low- and middle-income countries’. Having characterised ‘collective action failures at each stage of vaccine development that contributed to global vaccine disparities’, the authors propose in response a ‘multilateral model of global health governance’ which they constructively defend with reference to two significant philosophical principles. The principle of ‘responsibility to protect (R2P), developed in response to human rights atrocities during the 1990’, requires that ‘states must protect the citizens of another state… where a state is unwilling or unable to halt or avert serious harms its people are suffering’; this principle is supported by ‘the sober recognition that it is in each state’s interest to promote the interests of every other state’. And in order to put R2P into practice, we need the much older principle of subsidiarity, according to which each human ‘grouping, from the smallest to the largest…. should be allowed to make its unique and special contribution… without undue interference from any others, including the state’. With particular reference to justice in vaccine distribution, ‘subsidiarity recognises not only a multitude of global actors, but the intricacies of their relationships and the overlapping of their long-range aims’. In this context, nation states, while ‘they remain central’ must now be seen as ‘part of a growing ensemble of players’ with ‘subsidiarity and R2P… the normative principles best suited to orchestrating them.’ Jecker et al have here outlined a substantial agenda for the theory and practice of global health ethics, no less constructive but also no less challenging than that of Pratt and de Vries.