# introduction

We are two early-career bioethicists who are worried about the future of the field. While we are certainly appalled by the political climate of misplaced power, control, and influence that is evolving in the United States (1) and how this may affect the practice of bioethics, our motivation to write this perspective is also driven by the sudden “call to action” (2) for interprofessional collaboration in response to bioethics’ most privileged members — most often identifying with white, cisgender, and/or heteronormative groups — now feeling the sting of political alienation.

As relatively new members of the community, we have become disheartened by how the evolution of bioethics has effectively carved out the act of advocacy from its mainstream practice. Instead, most advocacy takes place within groups of marginalized bioethicists, including those from the Global South, who continue to fight for inclusion and justice through their practice. Despite the outstanding quality of work generated by these groups<fnref n="1" />, they are less likely to enjoy the same “bioethical legitimacy” — that is, widespread recognition and/or institutional adoption — as some of the field’s more privileged members, who have instead upheld and contributed to long-standing Western philosophical traditions that often parallel neocolonial paradigms. One can imagine how bioethicists who don’t embrace these traditions can implicitly become “outsiders” to the discussion, given how knowledge generated in Western practices continue to dominate mainstream ways of knowing.

Moving forward, we feel that to become effective advocates, mainstream bioethicists must learn from these groups and place their expertise at the forefront of the field’s work. While there are indeed calls to do so across institutions, these efforts often fall short of meaningful change in the long run, instead becoming exercises of tokenism and diversity washing. However, we believe that current political tides, albeit alarming, provide an impetus for such a shift insofar as they remind the community that “bioethics has an inescapable activist element because ethics itself is partisan, in the sense that it always entails a move toward the normative” (3).<fnref n="2" /> If this can be achieved through actionable initiatives, then ironically, in its attempts to quash ideological opposition, actions on behalf of emerging far-right political powers could end up facilitating the reworking of bioethics to render it stronger than it was before.

<footnote n="1">We wish to note that we too are members of these privileged groups. We do so to highlight the inherent limits to our perspective, to convey our intention to use this privilege to foster a more inclusive community of practice and to encourage those in similar positions to do the same.</footnote>

<footnote n="2">Although we will use them synonymously here, we fully recognize that there are nuances between ‘advocacy’ and ‘activism’ that are beyond the scope of this text (4).</footnote>
# The Advocational Imperative

While we propose that advocacy sits at the heart of bioethics, we must first acknowledge the waves of debate regarding its role that have occurred over the past 50 years (5). To begin, we must highlight positions on advocacy that we reject. For instance, some have argued for a style of advocacy that is inherently separate from the “legitimate” institutional roles in which bioethicists find themselves. They call for a “clear boundary between academic analysis and political engagement” so that bioethics as an academic field does not risk “losing its authority, primarily with governments and regulators, but also with other members of the academy and wider society” (6). They have described it as a “non-political and dispassionate stance in bioethics” (6).

We also resist the tendency to associate advocacy with lesser forms of, or the suspension of, reason. Those who are inspired to participate with communities or activist groups reportedly must then avoid said groups, to avoid limiting their views on the situation. A bioethicist’s strong interest in seeking out justice for vulnerable populations purportedly makes it “difficult then to subject ‘the underdogs’ truth’ to the same rigorous examination that would be applied in other contexts” (7). Such a bioethicist may also “just lack the courage to challenge what they privately consider to be their collaborators’ wrong-headedness” (7).

These lines of reasoning, seeking the demarcation of professional practice from advocacy, are of particular concern, especially in consideration of the “epistemic ignorance” that bioethics has historically endorsed (8). Indeed, despite efforts to make “itself useful to medicine and science, bioethics has failed to maintain sufficient independence and distance [from academic institutions of the Global North] to consistently fulfil its critical, corrective role” (9). Because while formally embedding bioethics in these faculties can be beneficial for enacting change, the field’s fundamental failure to address disagreements about bioethicists’ role as advocates — and the ignorance surrounding the duties of this role — has inadvertently led to the perpetuation, rather than alleviation of injustices.

Given the engagement that bioethics has with normative concepts like justice, owing to its conceptual roots in the post-World War II and civil rights movements, there is a clear imperative for bioethicists to act in an advocational manner (10). Understandably, some of those familiar with the field feel they “don’t know how we justify the claim that bioethics is not political or politically engaged” (5). Similarly, others have highlighted that when medical professionals engage in normative discussions, as opposed to empirical ones, “they are engaged in advocacy in a manner that is not ethically distinct from what a disability or patient advocacy group might do on behalf of its constituency” (11). Exactly where, and how, bioethicists should engage in advocacy is open to debate, as some recommend it for “achieving and reinforcing concrete change at the institutional level” (12), while others caution that some of “the norms and venues of rational discourse, as it has traditionally been practiced, may disproportionately serve the interests of the powerful” (9). As such, bioethicists must be acutely aware of the contexts within which they operate.

As Lisa Parker highlighted back in 2007, “most bioethicists are quite comfortable — materially and socially — within the admittedly nonideal political structures of the United States”, revealing the privilege of many bioethicists who, in acknowledging the imperfect nature of the political structures with which they interact, also recognize they may not be directly affected by them (9). Of course, a lot has changed since 2007; the nonideal political structures of the United States, among many others across the globe, have become much worse. Now, even the “quite comfortable” lifestyles of bioethicists are under threat, as it seems that despite the field’s habit of collaborating “less with the truly vulnerable than with those in power” (9), it’s still feeling the sting of ostracization amidst today’s sociopolitical climate. And with this sting, we hope, comes a wakeup call. We posit that instead of trying to find a way back into these settings by “compromising our ideals” (13), as bioethicists, we should acknowledge that we never fully belonged there in the first place. More specifically, we believe that bioethicists must recentre advocacy in their roles, so as to enhance their ability to address injustices stemming from ever-changing political structures, rather than conforming to the structures themselves.
# Recentring Advocacy

Our argument for recentring a mission of advocacy in bioethics was inspired in part by the call for contributions made by the Canadian Journal of Bioethics (“CJB”) which sought to promote discussion on the role that scholars from Canada and the United States embody as “Advocates, Activists, [and/or] Architects of Moral Space” (2). Although the CJB’s call for cross-border collaboration between Canadian and American bioethicists in response to the Trump administration’s recent mandates is well-intentioned, we worry that it fails to recognize all groups who should be included, if they wish to participate, in the discussion (14). However, this subtle tone of exclusivity is nothing new to the field of bioethics, suggesting that, beyond banding together to mobilize the practice against oppressive political structures, we must rebel “against the status quo in bioethics” and to seek a reworking of the practice as it stands (9,15).

We might first consider the redistribution of the previously mentioned “epistemic power” by giving weight to the perspectives of those with the most experience in the pursuit of justice; that is, those who, arguably, will bear the greatest impact of the ideological momentum being gained by far-right political structures (8,16). In doing so, we must discontinue the prioritization of Western values in bioethical discourse in ignorance of the plethora of alternative frameworks available (15). For example, the widely used “Four principles” remain a core pillar of the practice, and while the principles are marketed as a one-size-fits-all approach, their design is inherently grounded in Western belief systems (17). Traditional notions of autonomy, namely, remain a cornerstone of Western bioethics, marked by the presumptive priority of individual rights above competing interests built upon the “individual endeavor historically native to, and the vanguard of, European men” (18,19).

More recently, mainstream bioethical paradigms have been challenged, as many have come to recognize their incompatibility with communities across the globe (20). We might understand the inherent limitations baked into the individualistic notions of autonomy, for instance, with Feminist or Indigenous perspectives that consider autonomy as a relational construct based on one’s connection to factors such as their community, sociopolitical structures and the natural environment (17,21-23). And indeed, these challenges are warranted, as when narrow ideological imperatives are imposed on groups with differing values, we observe what has been described by some as a sort of “moral imperialism” (17,18). Such a stance comes from an “epistemological arrogance, supported by economic and political power and animated by the idea that the dominant systems of knowledge…are superior to those of other cultures and, therefore, have universal validity” (24). Moreover, this sort of moral imperialism is not unique to the field of bioethics but is reflected in numerous ideologies monopolized by privileged groups, which have historically led to problematic social movements and consequential injustices.<fnref n="3" /> Redistributing epistemic power in bioethics, then, means reducing the influence of mainstream ideologies and instead incorporating the variety of bioethical frameworks being drafted by communities across the globe, and for this work to be integrated into a much more intentional course correction of the field’s priorities.

We must also confront the exclusivity of the field of bioethics, as simply becoming a bioethicist can require enrolling in or engaging with some of the most elite academic establishments in the world, essentially to be trained — ironically — in how to be more inclusive. Consider how “Global Health” programs are distributed internationally (25). For instance, a recent survey revealed that many American bioethicists come from backgrounds of families with higher education, which are generally whiter, more liberal, and less religious than the overall population, further revealing how and why dominant perspectives in the field are associated with specific demographics (26). And so, instead of just “getting our house in order” as Jecker et al. (10) suggest, in order to incorporate “greater diversity within our own ranks”, we call for a more comprehensive remodeling of the estate to support effectively those facing greater structural barriers in the pursuit of a career, or simply voice, in bioethics.

Despite the uphill battles they face, bioethicists belonging to marginalized communities have continued to generate scholarship, hold conferences, and publish work on reconstructing the problematic pillars on which the field is built (27). We question, in the name of becoming a stronger collective, why it is that we tend to bring in the perspectives of Queer (28), Indigenous (29), Decolonial (30), Latin (31), African (15,32,33), or Black (34) bioethicists, to name but a few, when discussing gaps in our practice or issues specifically pertaining to these communities? By imposing these viewpoints as equal — at best — and as other, we reinforce the notion of Westernized, colonial frameworks having a central role if not taking a precedence, when really, these alternative frameworks are likely much better suited to address the ongoing injustices of contemporary society (29). While these recommendations may make some uncomfortable:

> [a]s we rationalize (to ourselves and others) why we are personally not responsible for bringing about needed change, we contribute to acts of displacement, and displacing blame, power, responsibility, labor, and compensation are themselves acts of injustice…even how institutional commitments to diversity can fail to provide adequate support and space for nonwhite scholars…Is our fear of giving up our power and privilege preventing us from realizing how we are displacing others from the power (and voice) that they deserve?...we must embrace an ethic of discomfort — being comfortable with the uncomfortable — in order to facilitate the necessary learning and growth in these areas
> — 35

From personal experience, it has been challenging for us as early-career scholars to engage in a field in which the voices of many of our colleagues continue to be suppressed by the same community of practice that claims to support them. We have seen too many good ideas discarded by the field of bioethics, which continues to fail in reckoning with its own class, gender, and racial ignorance. And while recognizing and celebrating the plethora of bioethical frameworks developed by communities across the globe is a positive step forward, instances like President Trump’s attacks on Diversity, Equity, and Inclusion (DEI) helps remind us that pluralism built on a foundation of colonial tradition achieves very little. It is unrealistic to believe that ideologically narrow frameworks operating alongside overfunded, unstructured attempts at inclusivity achieve a level of advocacy needed to bridge the opportunity gap between privileged and marginalized communities (36). However, we are also aware that bioethicists may not always be best suited to accomplish the goals of social change in isolation, because of both their primary skillset of speaking out against injustice as well as their embeddedness within the governmental and academic systems they strive to change. As scholars have pointed out, “it would behoove the field to celebrate, center, and learn from, but not co-opt the work of, individuals, organizations, advocacy, and activist groups like BLM [Black Lives Matter] who exist outside academia and are already working to combat injustice and inequality in health and society” (16,37). As such, we suggest that the interprofessional community of bioethics follow suit, not to enhance but to rebuild in a manner that diversifies and consequently strengthens its ability to achieve meaningful advocacy.

<footnote n="3">Consider “White-Man’s Burden”, Civilizational Feminism, and Liberal Imperialism to name a few.</footnote>
# Broader Nuances

Before concluding this commentary, it is important to note that our recommendations for recentring advocacy within bioethics are provided with contextual nuance. Firstly, despite bioethics being “a young product of the Western culture” (20), we are far from the first to highlight the importance of perspectives from outside the Global North; there have been decades of dialogue regarding the feasibility of a global form of bioethics, in contrast to universalist theoretical standards in Western cultures (20,23,24,38). These discussions have brought “glocal” or “transcultural” forms of bioethics to the forefront, which we commend as foundational normative work (24,38). Our goal has been narrowly focused to highlight the role these discussions have served as a form of intellectual advocacy, and that those in the Global North who tend to under prioritize them ought to instead learn from them to better understand the role that bioethics ought to play in society.

Secondly, as briefly touched on in the previous section, we hope that recentring the role of advocacy within bioethics does not fall into the same trap that “decolonizing” or “DEI” language has encountered in Western academia. With the former, simply using the language of decolonization and the colloquial motivations it implies can miss how “this term was invented by the imperialist to serve the purpose of what might be described in a loose sense as a red-herring, targeting those in the struggle against neocolonialism” (33). With the latter, striving to fight for the protection of DEI programs misses how they have largely been a “corporate pacification project dressed as progress” (39). With advocacy, the goal is to actively call out the misuses of power, even if in the form of intellectually rigorous materials that make some uncomfortable. It is important to understand that simply being bioethicists or using progressive language is ultimately insufficient, given how historically, even significant philosophers like John Locke, and the field’s management of their scholarly legacy, tend to glaze over their negative impacts on the eighteenth-century debate about slavery (40).
# Conclusion

Through our daily work as colleagues, we recognize that professional solidarity is paramount but understand the inherent limitations that our views raise for the much broader bioethics community. As such, our call for collaboration goes beyond immediate tensions in the Global North. While we don’t support the defunding of certain initiatives akin to efforts towards DEI, we respect how largely fruitless an endeavour they have been to meaningfully engage in critical discussion or meaningful change of the status quo of dominant Western traditions. If the importance of advocacy and solidarity with myriad communities can be seen within the field of bioethics, we feel that its future as both a field of study and a positive force for social change will be cemented regardless of the societal or political hurdles that it may face.

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