• Ethics

Earlier this year, the International Association of Bioethics (IAB) hosted the biennial World Congress of Bioethics (WCB) in Doha, Qatar. Understandably, controversy surrounded the decision to hold the conference there. Opponents thought Qatar’s human rights record rendered it incompatible with the IAB’s mission.1 2 Proponents felt that the location was overall justified to advance equitable participation in the WCB.3 4 The discussion about the Qatar venue was an important one. But unlike in real estate, where the mantra of ‘location, location, location’ highlights the often singular importance of geophysical coordinates, the debate about equity in global bioethics scholarship and practice is broader than where the WCB takes place. As we entered the intercongress time frame, it is helpful to consider in what other ways the IAB—and leading journals such as the JME—can contribute to equity in bioethics outside of events such as the WCB.

Publishing is a major part of academic engagement, visibility and influence. This volume of the JME comprises 18 contributions. Among the first authors, 9 are female and 9 are male. Using the World Bank taxonomy of countries’ economic status, 13 are from high-income countries (HICs), 3 from middle-income countries (MICs) and 1 from a low-income country (LIC). Six are early carer researchers (ECRs, within 5 years of their terminal degree).

A look at a single volume offers nothing but a snapshot. But it also stands in some continuity with trends in the field more broadly. Around 7% of the world population lives in HICs, 33% in MICs and 60% in LICs.5 Yet, relative to their proportion in terms of the global population, authors from HICs account for an outsize share of the bioethics literature,6 7 as well as in general medical research, global health research and medical education.8–10 The same pattern is found in those who participate in the WCB, especially when the WCB is located in a HIC. Participation rates at the 2022 WCB in Basel were HICs: 42%, MICs: 12% and LICs: 4%, that is, HICs shares were 7 times higher while MICs accounted for less than half their population share, and LICs for less than 1/10th (at the 2020 WCB/Philadelphia, which was held online due to Covid-10 rates were HIC: 42%, MIC: 12%, LIC: 10%, 2018/Bangalore, HIC: 36%, MIC: 32% LIC: 32%—ECRs were often captured separately and account for the remainder, where applicable, all data via IAB).11

People from HICs have far more access, presence and influence. Often, this is a result of historical patterns, colonial power dynamics and infrastructures that were established centuries ago and disenfranchised the majority of the world’s populations.12 And regrettably, many of the underlying dynamics continue to exert power.

The question is, then, what to do about this imbalance.

Journal editors are in a unique gate-keeping position, as they directly influence which authors get to publish which papers. The disproportionate representation of HIC authors aside, one central dimension is whether papers address issues that predominantly affect people in HICs or those in other regions. This issue’s feature article ‘Designing AI for mental health diagnosis: Challenges from sub-Saharan African value-laden judgements on mental health disorders’ by Ugar and Malele13; the research article ‘Ethical Issues in Nipah Virus Control and Research: Reversing Decades of Neglect in Bioethics’ Johnson et al. 14 and the student essay ‘Patient autonomy in an East Asian cultural milieu: a critique of the individualism-collectivism model’ by Max Ying Hao Lim are all particularly important in this regard, as they can contribute to addressing inequities in the body of bioethics scholarship and to correcting epistemic (in)justices.15 ,8 13 16–18

Ugar and Malele discuss the use of artificial intelligence and machine learning for the diagnosis and prognosis of diseases, especially mental health disorders, in a global context. Focusing on the setting of sub-Sharan Africa, they contend that the successes and accuracies of ML in diagnosing mental disorders ‘will depend on both the value judgements of what a particular clime considers a mental disorder and on some naturalist explanations of disorders. As a result, a generic or universal design cannot be effective’. The authors also offer concrete policy recommendations.

Johnson et al. make an equally timely contribution in their discussion of the Nipah virus control and research. Lacking efforts to address the virus represents another example of the perniciously enduring 10/90 gap, which the Commission on Health Research for Development coined in 1990 to capture that less than 10% of worldwide resources were devoted then to health research in Low- and Middle Income Countries (LMICs), where 90% of all preventable deaths worldwide occurred (and conversely, 90% of research was focused on conditions that predominantly affected the 10% of the population in HICs). The authors’ helpful discussion of the reasons for the neglect illuminates a complex web of explanatory factors, and they spotlight key areas for development in public health ethics and research ethics.

Max Ying Hao Lim examines a common dichotomy in which, almost in a tug-of-war, ‘western’ medical practice is often viewed as individualistic and ‘eastern’ as collectivistic. Centring on Hong Kong, China, he proposes that core values such as consent and autonomy ‘need not be culture-bound—indeed, their very existence mandates for them to be universal and non-derogable—but instead (that) cultural alignment occurs in the particular implementation of these principles.’

Evidently, these papers were published after being submitted to the JME by the respective authors, and editors can only work with the papers that enter their system. While trivial in process terms, spotlighting the entry point matters. Unfortunately, it is a fact that manuscripts from authors from HICs account for a vastly larger share of submissions, and more often betray the benefits from working in higher-resource settings, such as prior presentations in works-in-progress seminars, at conferences, or advice from, or coauthorship with, mentors who often are leaders in the field.

The IAB is the largest global bioethics association, and as such in a unique position to promote mentorship, collaboration and quality and equity within global bioethics. To prioritise which activities should be added outside of the WCB, the IAB launched a survey that is open to everyone (IAB membership not required; available until 31 December 2024 at: https://niptcanada.limequery.org/726375?lang=en). Regarding activities between WCBs, the survey asks respondents to rate the desirability of trainings and workshops focused on, among other things, conceptual and empirical methods; writing papers or conference abstract; or engaging with policy-makers, reporters, community and activist groups. The JME welcomes constructive ideas for how the journal can contribute further to effectively promoting equitable bioethics scholarship on an ongoing basis.

The eventual findings from equity-promoting initiatives will be the more meaningful for the field, the more people respond, especially colleagues from LMICs. It is also clear that the likely demand in terms of time required for training and mentorship will be considerable. Over past WCBs, several hundred 1-on-1 mentorship meetings between ECRs and more senior colleagues were facilitated by hosts, and workshops such as meet the funder or meet the editor were well attended. It is hoped that the generosity of mentors from the global bioethics community will also enable broader initiatives in the future. It is high time that we walk the talk when it comes to equity in bioethics scholarship and practice. By necessity, this requires a collective effort that calls on all of us. Failing to participate in contributing ideas or implementing new initiatives would render us complicit in sustaining an unjust and only sluggishly changing status quo.8 13