Most Bioethicists View Social Justice as an Important Part of Ethics Role

By Stacey Kusterbeck

Bioethicists view social justice as an important part of their work, according to a recent survey.¹ Researchers surveyed 355 U.S. and Canadian bioethicists. Most (80%) supported including social justice concerns in bioethics. Three-quarters said that social justice should be a key aim of bioethics scholarship.

“Bioethics as a field has really stayed in the realm of normative analysis, and has had difficulties incorporating sociological thinking into day-to-day work. We would love to see that, but it does require a lot more work in the field,” says Ryan J. Dougherty, PhD, MSW, HEC-C, one of the study authors. Dougherty is an assistant professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine and a clinical ethics consultant at Houston Methodist Hospital.

The bioethicists’ engagement with specific social justice topics varied. This reflects the heterogenous role of bioethicists at institutions. “Institutions do have the power to facilitate social justice work or restrict it. It points to the need for institutions to have a clear mission and to be very intentional in the type of role they want to have with the bioethicists in doing this type of work,” says Dougherty.

Bioethicists had mixed perceptions about institutional support for including social justice in their roles. “If a bioethicist is at an academic department is in a state with a lot of NIH (National Institutes of Health) funding, it might be easy to help facilitate projects related to social justice or have conversations about equity and injustice as part of consults. Bioethicists in other states might have less resources or be less encouraged to pursue projects of social justice,” observes Dougherty.

Part of the difficulty is that social justice work means different things to different people. “Often, when we think of social justice, we think about protesting or whistleblowing. We think about hot button topic areas — immigration, LGBTQ issues, and racial justice — which I do think are definitely part of the scope of bioethics work. But social justice can also appear in more subtle ways. It can shape the questions we ask and ensure that we are really listening to all the different stakeholders,” says Dougherty.

Regardless of whether the institution explicitly supports social justice initiatives or whether social justice is a formal part of the ethics role, individual ethicists can view their work through a social justice lens. “A lot of us do social justice work without explicitly naming it,” says Dougherty. “Social justice is about ensuring we understand the values and preferences of the most vulnerable patients in the healthcare system. But incorporating social justice at the bedside is a question that the field really needs to grapple with. In order for us to answer what that might look like, we need to be having conversations. It does require dedicated time and resources. And also, it requires the courage to stand by social justice work,” says Dougherty.

One way bioethicists can do this is by paying attention to power dynamics between patients and physicians. An ethicist may perceive that a physician is not really listening to a patient. The ethicists can try to amplify the patient’s voice by pointing out that the patient’s concerns are not documented in the medical record. The ethicist also can ask an open-ended question such as, “Could you speak to what your experience has been working with this patient?” This opens up the opportunity for the doctor to reflect on how their own biases might be hindering shared decision-making or respecting autonomy.

“Bioethicists can also examine how hospital policies might prioritize certain cultural norms and values that may marginalize underrepresented communities,” suggests Dougherty. Bioethicists can pay attention to patterns in the ethics consult service to see if certain issues are coming up more often in certain patient populations, compared to other populations. For example, at Houston Methodist, there are a lot of unrepresented patients. Many of these cases involve serious mental illness or socioeconomic factors. During ethics consults, ethicists consider what is in the patient’s best interest and seek to understand the patient’s preferences and values. “However, I am also very clear that part of the work is a form of social justice because I’m ensuring that a vulnerable person is receiving healthcare that I believe everyone is entitled to,” says Dougherty. An ethicist consulting on these cases can think about their own biases and assumptions, consider what the healthcare system or welfare system can and cannot do for the patient, and address moral distress that team members might experience. “If we zoom out to see the big picture from a social justice perspective, it lends to more holistic reasoning. In my role as a leader of a consult service, I am not always talking about social justice. But it is a way I orient myself to this type of work. Justice is one of the main principles of bioethics. In the same way I am always paying attention to beneficence, non-maleficence, and respect for autonomy, I am thinking about where justice is playing a role in a consult or a policy I am working on,” says Dougherty.

In Dougherty’s view, social justice simply reflects the bioethicist’s obligation to make sure that every patient is treated with respect and dignity. “I am not sure all institutions are accepting of someone who will wave the banner of social justice. But all institutions are interested in how we are serving vulnerable patient populations. Once we strip away the language of social justice, there is, underneath, a lot of framework and tools that will benefit everyone,” says Dougherty.

At a previous institution, Dougherty consulted on a case involving a patient who was wrongly accused of seeking pain medications inappropriately. The patient actually had an illness that was associated with severe pain. But in the context of the opioid crisis, her pain was not controlled adequately in the outpatient community because physicians were reluctant to prescribe opioids. Dougherty also took into account research showing that women’s pain complaints are taken less seriously than men’s. Dougherty asked the physician questions such as, “What would it mean to prescribe this medication? What sort of signs are you looking for that she is abusing substances? Are they present?”

After some reflection, the clinician reevaluated the situation and was open to prescribing the medication. “Social justice is about opening yourself up to being a better listener, and to being more attentive to how your actions have consequences on a larger scale,” explains Dougherty.

Other ethicists are exploring ways to call attention to larger issues of social justice in healthcare at their institutions. Two important topics that require the ethics committee’s attention are healthcare for undocumented patients and proposed cuts to Medicaid funding, according to Peter D. Murray, MD, MSM, FAAP, HEC-C, associate professor of pediatrics at University of Virginia School of Medicine. “Ethicists must collaborate with leadership to develop strategies that enable continuous healthcare delivery while also ensuring compliance with state and federal regulations. It is also essential for ethicists to collaborate with leadership to prepare for possible federal-level changes that could impact access to care for large portions of the population,” says Murray. For example, if a certain aspect of care becomes unavailable to a specific patient group because of directives, the ethics committee must work to ensure that those already receiving that care have alternative options for continued healthcare access and a clear explanation for why they can no longer receive that care at their institution. “When faced with significant cuts in funding, administrators may not consider all the implications of their actions, given the very real need to comply,” says Murray.

In Murray’s view, bioethicists also play a role in promoting the idea of administrative harm. “For too long, hospital administrators have not been held accountable for their decisions and their effects on patients. The concept of administrative harm has gained traction, at least in academic journals. Bioethicists have a role in both fostering the concept on a broad scale and ensuring that administrators are held accountable for their decisions,” argues Murray.

A specific topic that ethicists might help with is increasing transparency surrounding decisions made by senior leadership. An ethicist could best accomplish this by serving in an advisory role to hospital administrators, suggests Murray. “Hospital mission statements may remain words not translated into action without an ethicist who can step back from both clinical and administrative burdens of decisions and help guide leadership toward morally sound choices,” offers Murray.

Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.

Reference

1. Pacia DM, Baban SS, Fletcher FE, et al. A survey of attitudes toward social justice obligations in the field of bioethics. AJOB Empir Bioeth. 2025; Apr 17:1-12. doi: 10.1080/23294515.2025.2474915. [Online ahead of print].