The silencing of the epistemologies, theories, principles, values, concepts and experiences of the global South constitutes a particularly egregious epistemic injustice in bioethics. Our shared responsibility to rectify that injustice should be at the top of the ethics agenda. That it is not, or only is in part, is deeply problematic and endangers the credibility of the entire field. As a first step towards reorienting the field, this paper offers a comprehensive account of epistemic justice for global health ethics. We first introduce several different conceptions of justice and decolonisation in relation to knowledge, purposefully drawing on work emanating from the global South as well as the global North. We then apply those conceptions to the global health ethics context to generate a tripartite account of the layers of epistemic justice in the field: who is producing ethics knowledge; what theories and concepts are being applied to produce ethics knowledge; and whose voices are sought, recorded and used to generate ethics knowledge. These layers reflect that the field spans conceptual and empirical research. We conclude by proposing that, going forward, three avenues are key to achieve greater epistemic justice at each layer and to help decolonise global health ethics: namely, understanding the problem, dialogue and structural change.
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Global health ethics and epistemic justice
For several years, scholars have raised concern that global health ethics and the wider field of bioethics are missing voices and, in effect, primarily reflect the values of the global North.1–4 This includes issues of representation and diversity in academic scholarship and in the development of international ethics guidance documents aimed at the global South.5 Such concerns are particularly troubling in relation to global health ethics, a subdiscipline of bioethics that studies the ethical issues arising in public health, healthcare and health research in a global or global South context. In this paper, our understanding of global health ethics is informed by existing definitions of global healthi, while recognising that the term global health itself is under discussion,6 ,7 particularly with regard to the ‘what’ (the overall purpose/goal), the ‘where’ (the context in which it is undertaken) and the ‘who’ (the people designing, conducting and using knowledge from research).8 Salm et al conclude that ‘global health’ means many different things, and the definitions are conditioned by who defines global health and towards what ends.9 There are also important questions about the political project behind calls to decolonise global health, and who benefits from it. The scope of global health ethics should be and is informed by these definitional debates. Here, we define it as focusing on the ethics of public health and healthcare problems that are characterised by a global level effect or that require action beyond individual countries, and the ethics of research related to such problems.10 It further encompasses ethical issues that arise when externally funded public health programmes, healthcare programmes and health research are conducted in the global South—either with or without the involvement of stakeholders in the countries where research is conducted. Issues of investigation within global health ethics thus include fairness in collaboration, decolonisation, the ‘brain drain’, the inequitable global distribution of resources (eg, social determinants of health such as water, food, or housing), migration, poverty and health inequity.11
By not including fundamental values from other worldviews, the dominant bioethics paradigm is ‘an inadequate basis for understanding and implementing ethical global health research and practice’ that disadvantages people whose views or experiences are not included (Benatar, p325).1 The predominant epistemology in global health ethics (and the wider field of bioethics)—namely the one that treats humans as autonomous, self-interested, rational and competitive1—remains the same Eurocentric epistemology that has given rise to the myriad problems facing the world today, including those relating to the destruction of the environment as well as health disparities.12 Solving complex problems like health inequity ethically necessitates a global health ethics in which ‘multiple voices and alternative ways of being and knowing cannot only be recognised but celebrated’ (Mungwini, p4).13
This has led some to articulate a ‘crying need’ for a conceptual decolonisation (Tangwa, p103),2 arguing that bioethics is another instance of intellectual neocolonisation.14–18 Achieving greater epistemic justice in global health ethics is central to that goal. The concerns being raised about missing voices are, at their core, concerns about epistemic injustice. In using the term epistemic injustice, we refer to injustice as it relates to knowledge, which includes but is not limited to Miranda Fricker’s conception. We have chosen to use the term epistemic injustice because it clearly conceptualises the idea as a moral wrong. The silencing of the epistemologies and experiences of the many populations on whom global health ethics are inscribed constitutes a severe epistemic injustice. It endangers the credibility of the entire field and prevents it from being a truly global field: finding solutions to the dilemmas posed by modern medicine, public health and research through intercultural understanding of human obligations and opportunities.
So far, epistemic injustice in global health ethics is an area of limited conceptual exploration, though some work has been done in relation to global health research. Atuire and Bull proposed a three-dimensional ethical model of decolonisation for global health research that encompasses epistemic, hegemonic and commitmental elements.19 The epistemic element calls for revisiting the intellectual and cultural models governing the generation and sharing of knowledge.19 More specifically, it entails
a revisitation of the frameworks and conceptions of health, research and ethics to ensure first that they are not unjust towards indigenous knowledge systems and that they are open enough to include both indigenous and foreign knowledge systems… It requires critically unearthing African pre-colonial epistemic and value systems that are relevant to current challenges [Atuire and Bull, p.68].19
Bhakuni and Abimbola suggest it requires a dual focus on pose or positionality and on gaze or audience to explore opportunities for promoting epistemic justice in global health research.20 Pose is defined as the standpoint from which knowledge is produced. Gaze refers to the intended recipient of the knowledge being generated.20 Bhakuni and Abimbola identify several ways that testimonial and hermeneutical injustices arise when knowledge practices in global health do not prioritise local audiences or when members of marginalised social or epistemic groups have limited ownership of knowledge production and sensemaking in global health.20
This existing scholarship, however, largely fails to draw on much of the wider literature about justice and decolonisation related to knowledge. To avoid a ‘coloniality of justice’, we think it is vital to draw on such conceptions in addition to Fricker’s perhaps more well-known conception of epistemic justice or the application of thereof. Similarly, there has not yet been much engagement with interpreting such conceptions for global health ethics.
The contribution of this paper
As a first step towards reorienting the field, this paper offers a comprehensive account of epistemic justice for global health ethics. We first introduce several different conceptions of justice and decolonisation in relation to knowledge, purposefully drawing on work emanating from the global South as well as the global North. Because the work that emanates from the global South may be less familiar to readers, we spend time introducing the core ideas in that literature. We then apply those conceptions to the global health ethics context to generate a tripartite account of the layers of epistemic justice in the field. All three layers—knowledge-producer, knowledge-applied, knowledge-solicited—are of equal importance; none holds priority over the others. We conclude by proposing that, going forward, three avenues—understanding the problem, dialogue, structural change—are key to achieve greater epistemic justice at each layer and to help decolonise global health ethics.
In this paper, the terms centre, periphery, global North and global South are used rather than low-income, middle-income and high-income countries in order to bring the power dynamics inherent in knowledge production into focus. These terms are drawn from the literature we apply to develop our account of epistemic justice. The ‘centre’ refers to politically and economically dominant countries—some of which were formerly colonising powers—including for instance the UK, Europe, North America. The ‘periphery’ refers to the formerly colonised world.21 ,ii The global North-South distinction largely maps on to these terms, though the global South can be understood as larger than the periphery. For some, the term ‘South’ encompasses all those worldwide who experience systemic and unjust human suffering regardless of their geographical location.22
Concepts related to epistemic justice
Coloniality of knowledge refers to the epistemic hegemony of Eurocentrismiii, which originated during the era of colonisation and continues today. It is understood as any (historical or contemporary) attempt to obliterate the culture, epistemology and philosophy of colonised peoples.21 23 24 Colonialism helped establish the normative grounds for Eurocentrism’s hegemony. Its justificatory philosophies presented ‘the other’ as not being in possession of a rational mind—or the ability to reason13 25—and thus their epistemologies as unworthy of consideration. Seen in this light, non-European countries were positioned as ‘pre-ethical’ (Mbembe, p49).18 As Adams contends, in this way, colonialism ‘enacted another conceit of the colonial order of things: that Western reason is neutral, universal and objective; that it could be dislocated from the context in which it arose and applied elsewhere’ (Adams, p185).26
Scholarship on the coloniality of knowledge makes a central distinction between the centre and the periphery (2). It traces several effects of Eurocentrism’s epistemic hegemony on knowledge production today, namely: (1) subordination/erasure of theory, concepts, knowledge and methods from the periphery27 28; (2) an ignoring or rejection of the plurality of knowledge13 28; (3) a division of labour where theory is generated in the centre and subjects are present in the periphery29; (4) an ignoring of the history and effects of colonialism in terms of identifying the origins of problems and their solutions28 30 and (5) an education system where degree programmes in the centre and periphery only impart theories and methods from the centre.29 31 The presentation of the works of a few European philosophers as ‘universal truths’ means denying the possibility that these philosophical accounts were themselves located in particular historical moments and lived experiences and that they thus codified normative values prevalent at the time, including those assuming the superiority of the white race and that the ideals of ‘human progress’ equated to the developments and achievements of Western Europe.12 17
Eurocentrism’s epistemic hegemony also means that, while scholars’ physical location or place of birth may be in the periphery, their epistemic location may not be. As Grosfoguel notes,
the fact that one is socially located in the oppressed side of power relations, does not automatically mean that he/she is epistemically thinking from a subaltern epistemic location. Precisely, the success of the modern/colonial world-system consist in making subjects that are socially located in the oppressed side of the colonial difference, to think epistemically like the ones on the dominant positions. [Grosfoguel p213].29
A similar notion in African philosophy is Hountondji’s idea of ‘extraversion’, meaning being oriented towards external sources of authority.25 Mignolo31 further speaks to the ‘double bind’ of philosophers based in the periphery: their work is either deemed ‘excessively similar’ or ‘excessively different’ to philosophy emanating from the centre.31 The former label makes contributions not novel enough to matter, while the latter puts contributions in doubt as genuine philosophy.
Cognitive justice is a related concept, defined as the right of different forms of knowledge to co‐exist as part of dialogue and debate.22 It affirms the epistemological diversity of the world as a source of ideas, values and practices that can further global social emancipation. The knowledge of those considered disadvantaged and oppressed, in particular, should be engaged to drive the emancipation process.22 The concept draws attention to inequalities in the knowledge that is valued and produced 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. It calls for such inequalities to be rectified.32 33 The aim is to create new constellations of knowledge using both scientific knowledge and other types of knowledge, especially popular, lay and indigenous knowledges and the knowledges of oppressed peoples of the world at large.22
Other concepts of epistemic justice that have been the focus of much theoretical work by Fricker and many others are testimonial justice and hermeneutical justice.34 35 Testimonial silencing occurs when a speaker is accorded insufficient credibility by a hearer due to a prejudicial stereotype held by the hearer.34 36 Hermeneutical injustices occur when phenomena or experiences are not talked about or are poorly understood in a culture or society, and a group of people is unfairly disadvantaged as a result in terms of making sense of their social experiences and articulating them to others. Both testimonial and hermeneutical injustice can be either transactional or structural, where prejudice is inherent in interactions between individuals or within social structures.35
While Fricker focuses on testimonial silencing and hermeneutical injustice, other scholars have distinguished additional types and facets of testimonial injustice. Tuana notes that testimonial silencing constructs ‘epistemically disadvantaged identities’, where certain social groups are understood according to stereotypes that strip them of credibility.37 Collins further describes the ways in which the social identity ‘black woman’ can be rendered an epistemically disadvantaged identity.38 According to Jose Medina, testimonial distortions occur when individuals’ views and perspectives are made visible and audible but only in a distorted way. Here, the epistemic dysfunction at play is the active tendency to mishear and distort certain voices and perspectives due to a prejudicial stereotype held by the hearer.35 Kristie Dotson describes testimonial quieting as a form of self-silencing that occurs when a speaker perceives his/her audience as unwilling or unable to provide appropriate uptake. Three circumstances that routinely generate testimonial quieting are: (1) when the content of the testimony seems unsafe and risky; (2) when the audience demonstrates incompetence with respect to the content of the testimony to the speaker and (3) when there are patterns of pernicious ignorance that make it unlikely (if not impossible) to be understood and appropriately taken up in a given testimonial climate.36
Epistemic justice in global health ethics
Drawing on the various concepts of epistemic justice, we propose that it can be usefully conceptualised as occurring at three layers in global health ethics, reflecting the field’s conceptual and empirical dimensions: who is producing ethics knowledge; what theories and concepts are being applied to derive ethics knowledge and whose voices are sought, recorded and used to generate ethics knowledge.
The knowledge-producer layer encompasses who is producing global health ethics knowledge at the individual, institutional, funder and journal levels. At the individual level, the focus is on the extent to which diverse perspectives from the periphery are, or are not, represented in global health ethics scholarship through critical exploration of the dominant (and absent) voices publishingiv and speaking (eg, conference keynotes, oral presentations) as well as the power dynamics at play. By diverse, we mean diversity in terms of the perspectives that are less heard, including for instance perspectives from different geographical locations, genders, physical abilities, racial groups, languages and epistemic locations. By epistemic location, we mean whether ethics scholars are epistemically positioned in the global North and/or global South. Those located in the latter would draw on or interrogate concepts, values, philosophy and/or epistemologies from the global South in their work.
Also of particular importance is the extent to which testimonial injustices occur in global health ethics. What microaggressions and macroaggressions are experienced by scholars from the global South and to what extent does this testimonial silencing serve to maintain the epistemic hierarchy in global health ethics? Examples of such aggressions could be not being heard or taken seriously when making verbal contributions at conferences or meetings, being asked to define the relevance of one’s work in relation to work in the global North during peer review (an example of extraversion), being explained one’s own culture during peer review by reviewers who assume you are also a foreigner to the country they have worked in previously, or being awarded ‘poster presentations’ during major conferences where authors from dominant institutions or countries who present work done in your country or continent get keynote speaker slots, even when their work misrepresents the realities on the ground, or is less robust scientifically.
At the institutional level, the focus is on understanding better which institutions form part of the ‘centre’ of ethics knowledge production and which ones are in the ‘periphery’. As Abimbola and Pai remind us in the broader global health context: ‘Supremacy is there, glaringly, in how global health organisations operate, who runs them, where they are located, who holds the purse strings, who sets the agenda’ (Abimbola and Pai, p1627).39 It is thus important to interrogate where the ethics institutions that are deeply influential (ie, the ‘powerhouses’) in global health ethics are located. Which institutions publish the most work, are awarded the most grants, host international ethics conferences and host the scholars who articulate the principles and guidance used in global health ethics? Are they mainly in the USA, UK and Europe? If yes, emphasis should be on developing and nurturing strong and sustainable bioethics departments in the global South. Within all institutions contributing to global health ethics scholarship, it is crucial to assess whether their ethics scholars are diverse (ie, in terms of geographical location, demographics, epistemic location) and whether they equally value and reward their scholars for thinking from Southern epistemic locations compared with those who do not.
At the journal level, the focus is on the extent to which journals that publish articles on global health ethics are located in the centre or periphery of knowledge production, with particular scrutiny of the geographical and epistemic location of their editors-in-chief, their associate editors and their peer reviewers. Other important questions are whether they publish content not only from scholars from the periphery but also from Southern epistemic perspectives and whether their content and publishing in them is accessible (eg, financially and language-wise) to ethics scholars from the periphery. Journals’ practices have the potential to reinforce testimonial silencing and/or coloniality of knowledge via the process of extraversion. For career progression and to accumulate scientific credibility,40 ethicists at periphery institutions need to publish in leading international journals, many of which are based in or managed by people in the global North.v In order to stand a chance to publish in those journals, the risk is that scholars in the global South will write from a Northern rather than a Southern epistemic position and/or explain their work by reference to the cultures or knowledge of the global North. Where ethics scholars from the global South lack access to the scholarly literature in health and ethics journalsvi, they remain out of touch with work of other ethicists and lack the resources needed to critically think, analyse, synthesise and create new ethics knowledge.41 Their capacity to contribute to meaningmaking in global health ethics is then stifled.
At the funding level, the focus is on who is funding global health ethics scholarship and capacity development. Undoubtedly, as per the wider global health field, the money comes almost entirely from the USA, UK and Europe, but it is nonetheless important to acknowledge that this is not ideal. Additionally, it is important to interrogate whether funders’ global health ethics research priorities are set primarily by parties from the centre, excluding those in the periphery; whether the criteria and processes by which they allocate their money favour institutions and scholars at the centre of ethics knowledge production; and whether they fund scholars and institutions that are diverse in terms of geographical and epistemic location. If funding for global health ethics primarily goes to powerhouse institutions and scholars from the centre, that is, epistemically problematic.
The knowledge-producer layer is important as a matter of epistemic justice because it determines who defines the field’s guiding values, the global health ethics issues and concerns that are prioritised, and how they should be addressed. In a situation where the dominant ethics institutions and scholars are primarily from the centre, it is highly likely that the result will reinforce a coloniality of knowledge and continued hermeneutical injustice within the global health ethics field. Certain global heath ethics values, issues and concerns will not be articulated and conceptualised at all or as fully as they might have been. Guidance on how to address global health ethics issues and concerns may look quite different than it otherwise might have if scholars from the periphery were more involved in developing it.
To avoid this, a field called ‘global’ health ethics should ideally have scholars worldwide contributing to the knowledge it generates. Periphery institutions and scholars should be more equally represented in grant awards, first-author publications, and at conference keynotes and oral presentations. Over time, as more ethics scholars are trained in the periphery, the field should move closer to equal and diverse representation from the centre and periphery. Otherwise, global health ethics perpetuates a division of labour where theory and guidance are generated from the centre for application in the periphery. Ideally, ethics scholars worldwide will also represent Northern and Southern epistemic locations. Where ethics institutes at universities in the global North have a global health ethics programme or focus, it is important that their leaders and ethics scholars come from diverse geographical, demographic and epistemic locations. Among journals that focus entirely on or publish some content on global health ethics, a substantial number of editors, reviewers and authors should be based in the periphery and/or have a Southern epistemic location. Funders of global health ethics research should involve researchers from the centre and periphery as decision-makers in their priority-setting. They should ensure that their funding processes do not disadvantage periphery scholars and institutions relative to scholars and institutions from the centre. A critical component of moving towards epistemic justice is also creating the environmental conditions in which experiences of such injustice can be shared safely and constructively, with a genuine commitment to transformation by those who may have inflicted the harm and/or who have benefited from the injustice. Creating these conditions is the combined remit of scholars, institutions, journals and funders.
The knowledge-applied layer encompasses what epistemologies, theories, principles, values, concepts and methods are taught and used to derive global health ethics knowledge. By applied, we mean what knowledge is used to identify ethical concerns, to generate new ethical concepts and to generate ethical guidance; what knowledge is interrogated for applicability to global health ethics; and/or what knowledge is taught in ethics and philosophy programmes. Here, a key focus is on whether the theories, principles, values and concepts that are applied evenly reflect and value philosophical and ethical traditions from the centre and periphery. The starting point of global health ethics scholarship is important. As Mignolo notes, ‘of the many doors through which one could have entered the room of philosophy, only one was open. The rest were closed… As is well known, a room looks altered if you enter it from a different door’ (Mignolo, p65).31
Ethical concerns are often identified by assessing problems for consistency with ethical or philosophical theory, principles and concepts. Inconsistency locates particular problems as matters of ethical concern. Ethical guidance is often generated by applying ethical or philosophical theory, principles and concepts to such problems. Within philosophy and ethics, there are both theories from the global North (eg, Rawls’ theory of justice, utilitarianism) and global South (eg, Sen’s capabilities approach, African relationalism) to draw on to identify ethical concerns and to develop ethical guidance. Within bioethics, principles that can be applied for both purposes have been articulated for clinical ethics, research ethics, public health ethics and global health ethics—primarily but not exclusively by scholars in the global North (eg, see Beauchamp; Emanuel et al, Lee, Benatar et al).42–45
An important and persistent critique is that much of the work in global health ethics today continues to draw on theories, principles, values, concepts and worldviews from the global North.1 Tosam suggests that this epistemic hegemony links back to the colonial encounter and its justificatory philosophies, which devalued systems of ethics knowledge from the global South.3 Where philosophical and ethical traditions from the global North and ethics scholarship applying them are primarily used or extended by ethics scholars in their work, this reinforces cognitive injustice and a coloniality of knowledge. Ultimately, the result of the doors to Southern philosophy and ethical traditions being closed is likely hermeneutical injustice. What Southern perspectives on what is ethical would identify as concerns in global health and would prescribe to address them remain unarticulated.
The theories, principles and concepts taught in undergraduate, postgraduate, and doctoral philosophy and ethics degree programmes have a significant influence on what systems of knowledge ethics scholars go on to apply in their work. Where pluralism is ignored and theories and principles from the global North are mainly taught, this comprises a structural form of testimonial silencing. Theories and principles from the global South are implicitly suggested to be lesser, otherwise why else would they not be taught as part of an ethics or philosophy curriculum? It also reinforces a coloniality of knowledge via the process of extraversion and cognitive injustice. Where the fact that the philosophers whose works were foundational to bioethics and its core principles were also instrumental in elaborating notions of a ‘hierarchical racial ontology’ placing white Europeans at the apex of evolution is not highlighted or discussed, this also reinforces a coloniality of knowledge (Mungwini, p3).13 Broad calls and attempts to decolonise the curriculum seek to address this problem by actively diversifying not just the content of academic courses but also the teaching pedagogies used.
Beyond theory, values and principles, the knowledge-applied layer also encompasses what epistemologies and languages are reflected in global health ethics and its methods. Benatar et al draw attention to the fact that two distinct approaches to knowledge emerged from the Renaissance, with the former becoming the dominant epistemology and the latter being marginalised and silenced:
The first is a rational, atomistic, intellectual concept of the world that is characterized by linear, focused, analytic thinking based on observations, discrimination, measurement, and categorization that produces fragmented knowledge. The second is, by contrast, a romantic, intuitive, imaginative world-view, based on direct experience of reality with an expanded state of awareness that considers knowledge as relational […], synthesizing, holistic, non-linear, and transformative [Benatar, p333].1
The former epistemology attaches value to methodologies that are rational, scientific, quantitative and reductionist. Within global health ethics, quantitative methods are not the most commonly used methodologies. It is nonetheless important to consider whether the conceptual and empirical methods used by the field reinforce the dominant Eurocentric epistemology and fail to incorporate methods drawn from epistemologies from the global South.
At present, approaches drawing on epistemologies from the global North are given prominence by education systems in most countries worldwide. In Africa, for instance, Behrens contends that education continues to be ‘dominated by the methods, theories and presuppositions of the colonial masters who first created the universities in Africa’ (Behrens, p95).46 Benatar et al further highlight the ‘epistemic hierarchy’ that is ‘embedded in the education process’, where methodologies that are rational, scientific, quantitative and reductionist are valued over other methodologies (Benatar, p327).1 Thus, what conceptual and empirical ethics methods are taught in ethics education programmes could well reinforce hierarchies that place the highest value on epistemologies from the global North.
To achieve epistemic justice, it is imperative that epistemologies, theories, principles, concepts and methods from the global South are increasingly taught and applied in global health ethics. Here, we are not saying it is unnecessary to teach and use knowledge from the global North in global health ethics. Cognitive justice means valuing different types of philosophy, ethics knowledge and epistemologies. Values and ideas from any part of the world can be used to identify ethical issues and concerns and to generate ethical guidance on health matters occurring globally or in periphery contexts. The problem is when theories, epistemologies and principles from one part of the world dominate, the context of their origins is ignored and knowledge systems from elsewhere are silenced.
Education programmes and scholarship on global health ethics need to achieve a balance between the global North and South in their content on and use of philosophical and ethical traditions, respectively. To avoid Eurocentrism, the historical location of theories, concepts, values and ethical traditions should be openly discussed when teaching them to students. This specifically includes a reckoning with sexism and racism in the lives and works of the philosophers whose scholarship is foundational to bioethics.47 It also requires building awareness and understanding of the extent to which contemporary relations of dependency and extraction—which are structural determinants of many of the problems that global health ethics focuses on—are modelled on colonial-era relations and power hierarchies.
Increasing the visibility of knowledge from the global South in global health ethics further entails generating more ethical theories, principles and concepts from a Southern worldview to enrich the field. As Barugahare affirms:
another aim, which deserves attention, is to discover and articulate vital ethical principles and theories from an African worldview; principles that can be used to effectively address contemporary African health needs and challenges [Barugahare, p98].4
This is an important task for all ethics scholars working from a Southern epistemic perspective. Funders, journals, universities and PhD supervisors’ roles as knowledge-producers are critical here too. Even if trained to think from a Southern epistemic perspective, scholars likely will not generate such theory or apply knowledge from the global South in their work if other actors don’t encourage and reward them for doing so.
The knowledge-solicited layer encompasses whose voices are solicited, recorded and used in empirical ethics research and in international ethics guideline development. Here, we mean whose voices are sought to: (1) articulate the ethical values that are important in global health, (2) describe the ethical issues and/or concerns they experience in global health and/or (3) develop guidance on how to address those issues and concerns and to put the values into practice. Epistemic justice would call for accessing and listening to voices with key insights and experience of global health matters, especially those who are less heard or unheard in ethics research. This would mean drawing out the voices of global health actors in several categories. These categories include not only health workers, health managers, health policy makers, funders and researchers but also people with lived experience of illness or disability, their families and carers, fieldworkers, members of socially marginalised groups and members of the public/community. Inclusion of such people and their experience and knowledge is imperative to achieving the kind of epistemic justice we speak about in this paper. It will allow the people who are normally targeted by global health interventions— it’s audience, so to say—to define what ethical concerns need to be considered, which values and principles need to be brought to bear, and for what reasons. It also allows a transition away from an overemphasis on professional and academic knowledge and expertise as being the only, or most important, form of expertise that matters.
If drawing solely on the perspectives of ‘expert’ clinicians and researchers, global health ethics scholarship and guidance will reinforce hierarchies of knowledge that devalue or ignore the knowledge and capacity of people with lived experience and members of the public to contribute to work identifying ethics issues and developing ideas about how address them. Soliciting their views on global health ethics will help address testimonial injustices, help democratise knowledge within the field, and avoid reinforcing cognitive injustices. Additionally, diverse views on global health ethics should be solicited from both the periphery and the centre, including those considered disadvantaged or marginalised. Cognitive justice emphasises soliciting views from all those globally who experience systemic and unjust human suffering.
If global health actors from the centre and periphery, spanning a range of categories and including those considered disadvantaged and socially marginalised, do not participate in empirical ethics research, hermeneutical injustices in global health ethics will likely result. Certain ethical issues, concerns and values will not be conceptualised because certain actors are excluded from meaning-making. Whatever ethical guidance is developed by scholars will be lacking, as it will not include their insights and ideas.
At the guideline development level, the focus is on whether diverse perspectives from the centre and periphery are evenly represented and whether processes of guideline development and revision are epistemically fair. The former encompasses scrutinising the diversity and balance of working group composition and those consulted, that is, are they diverse in terms of geographical location, experience, race, gender, physical ability, language and epistemic location? Are numbers from the centre and periphery similar? The latter encompasses understanding which participants are likely to experience testimonial silencing, distortion or quieting and ensuring that they are empowered to meaningfully contribute to the discussions. For instance, cultural differences in approaches to public speaking may mean that some people—those who wait to be asked for their opinion rather than voicing their opinion without invitation—can be effectively silenced during deliberations. Similarly, people for whom English is not a first language may not feel comfortable speaking and contributing. If the groups of people charged with developing guidelines are not diverse and the process of development is not epistemically fair, the risk is again hermeneutical injustice. The resulting guidelines do not address the actual realities or lived experiences of the people for whom the guidelines were developed.
Beyond procedural aspects of guideline development, the extent to which Southern perspectives are incorporated into the resultant guidelines and how the guidelines deal with North-South disparities also merits scrutiny. Are such disparities presented as ahistorical facts and unrelated to ongoing power and economic inequities and colonial origins? Doing so would reinforce a coloniality of knowledge and, as Brisbois and Plamondon state, ‘global health ethics—if carried out in a way that naturalises poverty in the global South—may therefore script global health researchers into ways of thinking and acting that perpetuate North-South inequities’ (Brisbois, p148).48 Ultimately, epistemic justice calls for guidelines to reflect Southern perspectives and to acknowledge the origins of North-South disparities.
Several objections can be anticipated to the account of epistemic justice for global health ethics that is derived and proposed in this paper. First, it could be argued that the account should be directed at the wider bioethics field, rather than focused narrowly on global health ethics. Concerns about missing voices have been levied in relation to bioethics as a whole, not just global health ethics. Existing data also shows epistemic injustice exists in relation to the wider field.41 49
We have taken global health ethics as a starting point because, as this is the field to which our own scholarship has contributed, we feel we have both an obligation and sufficient contextual understanding to articulate an account of epistemic justice for this narrower field. We also feel there is moral urgency to do so, as previously noted. On the matter of whether the tripartite account of epistemic justice should be applied to bioethics, we agree that there are reasons for doing so. Today, ethics scholars are trained and conduct bioethics research in many different countries within the global North and South. Yet the voices of scholars and institutions from the global North dominate and, within the global North, it is quite likely that certain voices dominate while others are marginalised. Like global health ethics, bioethics needs to transform to become more epistemically just. The diversity of the global North needs to be better captured in bioethics in terms of who is producing ethics knowledge, what knowledge is being applied and whose voices are being solicited. The three layers of our account would thus, we think, still apply to the wider bioethics field, but more consideration is needed of who is likely marginalised within it, what diversity means within it and how that diversity can be captured at each layer.
Greater balance between the global North and global South across the three layers of epistemic justice would, we think, be of immense benefit to bioethics. Where knowledge is produced, applied and solicited from the global South, it will undoubtedly be useful and applicable to bioethics topics. If our proposed account is applied to bioethics in general, it suggests, as we believe, that ideas from the global South and North are relevant to bioethics. But how should an emphasis on accessing voices in the global South be balanced with an emphasis on accessing voices in global North? To extend the proposed account to bioethics, greater consideration would be needed on what an appropriate balance between the two entails.
Another objection that could be raised is that greater epistemic justice calls for global health ethics to advance a transcultural framework of ethical values and principles. But are there any global values and principles in the sense that they are commonly shared among all human beings? The prospect of a transcultural framework is controversial.50 In response, we note that it is not clear that greater epistemic justice and any transcultural framework of ethical values and principles that emerges would necessarily give rise to universal values and principles. It is possible that such a framework would identify such principles. However, even then, whether their application is universal or whether there would be permissible variability in terms of how they are applied across contexts is another matter to consider. It is also possible that dialogues would generate a different answer: perhaps there are no absolute, universal values and ethics is to a large extent a matter of context and interpretation. In such a case, a transcultural framework would look considerably different than existing paradigms in global health ethics, which, from our experience, often consider principles and values to be largely universal but their application to be context-specific.
A third critique to our proposed account might be that global values and principles have largely already been identified (eg, respect for persons, justice, solidarity, equity, trust) and thus greater epistemic justice in global health ethics is unneeded. In response, we note that comments like this are a form of epistemic (testimonial) injustice of their own accord. We acknowledge that it may possibly be true but emphasise that it cannot be known definitively until the field is better informed by theories, epistemologies and concepts from the global South. Additionally, that global values and principles have been articulated does not mean that the way they have been interpreted or applied is reflective of how different ontologies and cultural practices give sense to them. An example is the principle of solidarity, which, while used in both African and European philosophy, is understood differently across them. Epistemic justice requires us to interrogate these differences and how they apply to bioethics and to develop constellations of knowledge informed by different ways of understanding solidarity.
Where to from here?
To achieve greater epistemic justice in global health ethics, we suggest three avenues are key in light of our proposed account.
Understanding the problem
The proposed account offers a research agenda for collecting comprehensive evidence about epistemic (in)justice in global health ethics. By gathering evidence at the knowledge-producer, knowledge-applied and knowledge-solicited layers, the field can generate a much better picture of where it needs to improve and where it is doing well. A range of research methods can be brought to bear in this mapping exercise (table 1). To be epistemically just, it is imperative that evidence gathering uses research approaches that recognise context and intersectionality and that specifically give voice to the perspectives of those who are neglected.51 52 To us, this means employing research approaches that empower participants—for instance, by fostering deliberation and co-creation of research questions and methods. Examples could be action research or participatory research design methods. It also means that evidence gathering is led or co-led by people who are geographically or epistemically located in the global South. Finally, it is important that evidence is interpreted in ways that recognise the interplay between structural factors and individual agency, in the way that for instance a critical medical anthropology study would (see Haynes et al).53
While the options we identify in table 1 are not exhaustive, they comprise a useful starting point. Gathering evidence across the three layers goes farther than any existing work, which has so far generated some data about the knowledge-producer level in terms of individual authors and journals (see Borry et al, Chattopadhyay et al, Robson et al).41 49 54
To make knowledge from the global South visible and valued in global health ethics, core components of cognitive justice are pertinent: (1) acknowledging the plurality of knowledges and (2) undertaking intercultural translation and mutual learning. The former means recognising that a diversity of epistemologies and knowledges exist in the world and demonstrating epistemic respect for them.22 Intercultural translation means undertaking dialogue and translation among different knowledges and practices to develop new constellations of knowledge.22 Dialogue between knowledge producers with diverse perspectives is needed at the level of the foundations of global health ethics and at the level of global health ethics studies. The former means creating zones for broad dialogue between those based in the global North and South about the field’s underlying methods, epistemologies, and foundational concepts and theories. The latter means creating zones for dialogue when designing and conducting individual ethics research projects and programmes. At both levels, what is essential is establishing mutually respectful, intellectually curious dialogues between people from different locations, backgrounds and epistemic perspectives. Over time, dialogue at the two levels will ideally lead to a shift in the epistemological, methodological and conceptual foundations of the field of global health ethics, which, in turn, will lead to changes in how it is conducted and with whom and will generate richer constellations of meaning.
But beyond merely fostering dialogues about the knowledge that lies at the basis of global health ethics, what is also essential is organising difficult conversations55 about how epistemic injustice in global health ethics has affected individuals across career spectrum, including conversations about power and privilege as well as experiences of discrimination, marginalisation and exclusion. Amongst others, this will involve the creation of ‘safe spaces’ where people whose perspectives and experiences have been silenced can share those experiences. Work that is already happening under the umbrella of the Equality, Diversity and Inclusion in Science and Health Coalitionvii can be a model in this regard.
Structural changes in global health ethics are needed to generate dialogue and achieve greater visibility of the global South in terms of who is producing knowledge, what knowledge is applied and whose knowledge is solicited. These changes are needed in how global health ethics is funded, taught, evaluated and published. Funders, research institutions, education programmes, journals and ethics scholars are thus in a prime position to help foment and make these changes. While it is beyond the scope of this paper to comprehensively articulate these actors’ specific responsibilities, we make some initial suggestions in table 2 as to what they might entail. Depending on the outcomes of efforts to measure epistemic injustice in global health ethics, those areas where the injustices are worse than in others should be given priority focus to remedy.
The concept of justice is core to the work taking place in global health ethics. Yet the field silences the epistemologies and experiences of the very populations on whom global health ethics are inscribed, affecting its credibility and adequacy as a basis for understanding and implementing ethical global health research and practice. Promoting epistemic justice should thus be at the top of its agenda.
As a first step towards reducing epistemic injustice in the field, we conceptualised epistemic justice for global health ethics at three layers, namely the knowledge-producer, knowledge-applied and knowledge-solicited layers. There is urgent and important work to be done at all three layers, consisting of both gathering evidence about the kinds of epistemic injustices that regularly occur in global health ethics and reimagining the way in which global health ethics is funded, taught, conducted and communicated. Central to this work is the creation of opportunities for scholars from peripheral geographical or epistemic locations to both share their experiences of testimonial silencing and to be central to the reimagining of the way global health ethics is done.
In a cultural and political environment where the emphasis is on the processes of transformation and inclusion, the time to reimagine global health ethics is now. The work required is vast and requires the combined attention, commitment and efforts of all involved in global health ethics—from young students to established scholars, funders and journal editors. What should motivate this work is the exciting prospects afforded by the vision of a transformed, inclusive global health ethics we set forth in this paper. If successful, an epistemically just global health ethics will generate original and incredibly exciting opportunities for scholarship, identify new concepts, advance our engagement with existing concepts and potentially offer completely new ways of considering some of the main ethical challenges facing the global human population today.
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study.
Patient consent for publication
Contributors BP and JdV came up with the paper topic together. BP led the drafting process. Both authors substantially revised the paper for intellectual content and approved the version submitted for publication. BP accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.
Funding JdV was funded by Wellcome Trust (Grant number: WT 222784/Z/21/Z).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
↵A common definition of global health is ‘an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasises transnational health issues, determinants, and solutions’ (Pinto and Upshur, p8).6 As it is commonly applied, global health also strongly focuses on improving health in low-income and middle-income countries.
↵The centre-periphery distinction was first coined by the Argentinian economist Raúl Prebisch. It has since been used in literature on coloniality of knowledge and Southern theory.
↵Eurocentrism is a perspective of knowledge that rests on several ‘foundational myths’, including that: (1) civilisation and knowledge originated in Western Europe, thereby erasing the possibility of knowledge emanating from elsewhere, (2) modernity was a pristine development starting in ancient Greece and culminating in eighteenth-century Europe, ignoring/erasing the role colonialisation played in making such development possible, and (3) Europe serves as the model for every other history, representing the apex of humanity’s progress from the ‘primitive’ to the ‘modern’.30 31
↵Some work has explored this already. Robson et al performed a critical interpretive review of the global health ethics literature. Of the literature selected, 151 articles (88%) were written by authors in high-income countries (HIC), as defined by the World Bank country classifications, 8 articles (5%) were written by authors in low-income or middle-income countries (LMIC), and 13 articles (7%) were collaborations between authors in HIC and LMIC.54 Borry, Schotsmans, and Dierickx showed that, of 4029 research articles gathered from nine international bioethics journals, authors from high-income countries contributed to 96.1% (3,873 of 4,029) of the publications, in contrast to 3.9% (156 of 4,029) for those from LMICs. Borry, Schotsmans, and Dierickx reported no publications at all from 123 of 154 LMIC countries (79.9%).49
↵Robson et al found that only one bioethics journal was based in the global South: the Indian Journal of Medical Ethics. The dominant journals in global health ethics (eg, American Journal of Bioethics, Developing World Bioethics, Bioethics) were all based in the global North and so were their editors-in-chief, with the exception of Developing World Bioethics. It had one editor in chief from Brazil and 75% of its section editors were from South Africa.54 Similarly, Chattopadhyay found that approximately 95 percent of editorial board members of leading bioethics journals were based in (very) high-HDI (human development index) countries, less than 4 percent were from medium-HDI countries, and fewer than 1.5 percent were from low-HDI countries. Eight out of 14 had no medium- or low-HDI country editorial board membership.56
↵Chattopadhyay et al showed that such exclusion is quite common in bioethics: ‘None of the subscription-based leading international bioethics journals (measured in terms of their impact factors) are freely accessible to bioethics scholars in all low resource countries… As we noted in the preceding, articles of interest to bioethicists are also published in journals that do not identify as bioethics journals; looking at top-ranking general medical journals—likely sources of bioethics articles—we find that here too, scholars in LMICs have limited and uneven access’(Chattopadhyay et al, p4).41
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