compte rendu / review

What Black Health Means for Bioethics in Canada

Manisha Pahwaa

Résumé

Abstract

Black Health de Keisha Ray est un examen poignant des déterminants sociaux, politiques et culturels de la santé et du bien-être des Noirs aux États-Unis. Cette revue réfléchit aux implications potentielles de Black Health pour l’équité en matière de santé et à ce que la bioéthique pourrait être et faire pour tout le monde au Canada.

Keisha Ray’s Black Health is a poignant examination of the social, political, and cultural determinants of Black people’s health and well-being in the United States. This review reflects on the potential implications of Black Health for health equity and what bioethics could be and do for everyone in Canada.

Mots-clés

Keywords

santé des Noirs, racisme anti-Noir, déterminants sociaux de la santé, déterminants structurels de la santé, bioéthique, équité en matière de santé, Canada

Black health, anti-Black racism, social determinants of health, structural determinants of health, bioethics, health equity, Canada

Affiliations

a School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada

Correspondance / Correspondence: Manisha Pahwa, manisha.pahwa@mcgill.ca

introduction

Keisha Ray’s Black Health, published by Oxford University Press in 2023 (1), is about the past, present, and future of Black people’s health and well-being in America. Ray discusses the social and structural dimensions that make up Black people’s health and well-being, urging bioethics to help address the unjust conditions that cause Black people to have poorer access to health care and experience greater health disparities. While Ray’s focus is on the intersection of the lived experiences of Black people’s multiple identities with anti-Black racism in the United States, Black Health is strongly relevant for Canada, where diverse Black individuals, families, and communities experience anti-Black racism in health and social institutions that Ray covers in Black Health. Ray brings Black lives to the forefront by expertly weaving stories, statistics, and statements that accumulate to achieve the book’s goal, and in a manner that is as accessible as it is rigorous, making Black Health a core text for bioethics education, research, and practice.

Black people represent approximately 4.3% of the total population in Canada (2) and include a tremendous diversity of identities, histories, cultures, languages, religions, families, and genetics. Black people are less likely to have access to palliative care (3) and have less exposure to residential greenness (4) compared to White people in Canada. During 2020, rates of COVID-19 mortality were highest among Black people in Canada, especially in the low-income category (5). Black women aged 40-49 years are more likely to die from breast cancer compared to White women in this age group in Canada (6). A close reading of Black Health ensures that our understanding of Black people’s health is informed by analyses of how social, political, and cultural institutions and practices marginalize Black people’s multiple identities and cause excess burdens of morbidity and mortality that can and should be prevented.

Bioethics and health equity for Black people in Canada

If bioethics in Canada is to do more for Black people’s health, then Black Health can contribute as a compass and guide. First, the book demonstrates the vital importance of Black people self-determining the ethical issues that affect their health and well-being. Ray has previously critiqued bioethics for its preoccupation with the examination of relatively few issues such as abortion, end of life care, and emerging technologies (7). She has described Black Bioethics as a rebellion against bioethics; a “we’ll do it ourselves” attitude ensuring that the injustices experienced in the everyday lives of Black people are recognized as bioethical issues warranting the use of bioethics theories and methods and attention from bioethicists (7). In Black Health, Ray examines why hospital births are unsafe for Black people, why Black people’s pain is not believed, whether cardiovascular disease is part of the Black experience, and whether it matters where Black people sleep. In her choice of discussing these topics, Ray affirms and makes explicit the self-determination of Black people while clarifying the scope of issues that would define a Black Bioethics.

Second, Black Health amplifies the importance of justice theory in bioethics scholarship, applying an intersectional framework to understand how Black people’s multiple marginalizations within social institutions shape their access to health care and health outcomes. Ray focuses on health care, housing, economic, and legal institutions, demonstrating how and why these institutions have not been designed to give Black people what they need for health. In a separate exposition of the bioethics of environmental injustice, co-authors Ray and Cooper describe how environmental exposures that map on to race cause higher rates of morbidity and mortality among Black children and communities in the United States, e.g., from asthma and COVID-19 (8). These authors argue that a commitment to vulnerable populations and justice in bioethics are core reasons why environmental health should be prioritized in bioethics. Indeed, a commitment to justice in bioethics is a key reason why the social, political, and cultural determinants of Black people’s health should be pressing matters for bioethics, and lead the field to leverage the full weight of justice theory to undertake this important work.

Third, Black Health points towards methodologies that can be used to foster deeper understandings of Black people’s health with a strong role for first-person accounts authored by Black people. Throughout the text, Ray incorporates direct quotes and stories describing how racism and discrimination adversely affect the ability of Black people to, for instance, avoid exposure to COVID-19, live in better neighbourhoods, and generally access the circumstances and material resources needed for health and well-being. This approach is deliberate as Ray aims to humanize “the examination of Black health during a time when so often Black people’s humanity is denied” (p.5). Any methodologies that ensure that Black people are the tellers of their own stories and that promote the sincere representation of Black people on their own terms are suitable candidates for Black Bioethics scholarship.

Black Health, bioethics, and health equity for racialized people in Canada

Black Health is for Black people’s health and well-being. As a South Asian person, my decision to review Black Health was fraught with the historical and contemporary complexities of Black-South Asian relations. Yet the resonance with some of my own lived experiences prompted me to openly explore the potential significance of Black Health for people in Canada whose health outcomes are profoundly shaped by racism, discrimination, colonialism, and immigration. In this light, Black Health is also a provocation for further creative thinking, dialogue, and action about what bioethics can be and do for health equity for racialized people in Canada.

If bioethics is to help advance health equity, then bioethics research should include an orientation towards informing transformation in the design of health and social institutions that influence racialized people’s health. Stories generated through qualitative research, for example, vividly expose causal mechanisms within institutions that systematically undermine racialized people’s health. When integrated with ethics theory (9,10), stories are a powerful type of empirical evidence that can contribute to the development of normative claims about how health and social institutions should be designed along these mechanistic pathways to give racialized people what they need. Participatory approaches ensure that racialized people co-create norms and their implementation through processes of dialogue and iteration oriented to their needs and contexts (9). Based on my lived experiences, I anticipate that air pollution, precarious work, and poor-quality housing are some of the stories that may arise through such participatory research. In these situations, normative claims that target environment, labour, and housing institutions could be justified by ethics theory from philosophical traditions that have sustained the health and well-being of communities worldwide over millennia.

As a field concerned with moral experience (11), action, and human flourishing, bioethics can and should be widely inclusive. Dispositions of creativity, open-mindedness, and epistemic humility are needed to carry out participatory empirical bioethics research that aims to transform institutions (12). By embracing diverse experiences and values, bioethics can not only contribute to health equity for racialized people, but also to peace and human flourishing in democracy (13) – making Black Health an inspiration for what bioethics could be and do for everyone.

Reçu/Received: 24/02/2025

Publié/Published: 28/04/2025

Remerciements

Acknowledgements

MP bénéficie d’une bourse d’excellence en recherche, de diversité et d’indépendance en début de carrière des Instituts de recherche en santé du Canada. Elle est reconnaissant à Tamika Jarvis et Ahmednur Ali pour leurs commentaires généreux sur les versions préliminaires de ce manuscrit.

MP is supported by a Research Excellence, Diversity, and Independence Early Career Transition Award from the Canadian Institutes of Health Research. She is grateful to Tamika Jarvis and Ahmednur Ali for generous feedback on drafts of this manuscript.

Conflits d’intérêts

Conflicts of Interest

Aucun à déclarer

None to declare

Édition/Editors: Julien Brisson & Patrick Gogognon

Les éditeurs suivent les recommandations et les procédures décrites dans le Core Practices de COPE. Plus précisément, ils travaillent pour s’assurer des plus hautes normes éthiques de la publication, y compris l’identification et la gestion des conflits d’intérêts (pour les éditeurs et pour les auteurs), la juste évaluation des manuscrits et la publication de manuscrits qui répondent aux normes d’excellence de la revue.

The editors follow the recommendations and procedures outlined in the COPE Core Practices. Specifically, the editors will work to ensure the highest ethical standards of publication, including: the identification and management of conflicts of interest (for editors and for authors), the fair evaluation of manuscripts, and the publication of manuscripts that meet the journal’s standards of excellence.

references

1. Ray, K. Black Health. New York: Oxford University Press; 2023.
   2. Statistics Canada. Table 98-10-0337-01: Visible minority by ethnic or cultural origin: Canada, provinces and territories, census metropolitan areas and census agglomerations with parts. 26 Oct 2022.
   3. Bassah N, Beranek J, Kennedy M, Onabadejo J, Santos Salas A. Inequities in access to palliative and end-of-life care in the black population in Canada: a scoping review. Int J Equity Health. 2024;23:81.
   4. Pinault L, Christidis T, Toyib O, Crouse DL. Ethnocultural and socioeconomic disparities in exposure to residential greenness within urban Canada. Health Rep. 2021;32(5):3-14.
   5. Gupta S, Aitken N. COVID-19 mortality among racialized populations in Canada and its association with income. Statistics Canada Catalogue no. 45-28-0001. 30 Aug 2022.
   6. Wilkinson AN, Ng C, Ellison LF, Seely JM. Breast cancer incidence and mortality, by age, stage and molecular subtypes, by race/ethnicity in Canada. Oncologist. 2024 Nov 2:oyae283.
   7. Ray K. Black Bioethics and how the failures of the profession paved the way for its existence. Bioethics Today. 6 Aug 2020.
   8. Ray K, Cooper JF. The bioethics of environmental injustice: ethical, legal, and clinical implications of unhealthy environments. Am J Bioeth. 2024;24(3):9-17.
   9. Metselaar S, Voskes Y, Molewijk B, Widdershoven G. Implementation in bioethics: a plea for a participatory and dialogical approach. Am J Bioeth. 2020;20(4):78-80.
  10. Ives J, Dunn M, Cribb A, editors. Empirical Bioethics. Cambridge: Cambridge University Press; 2017.
  11. Hunt MR, Carnevale FA. Moral experience: a framework for bioethics research. J Med Ethics. 2011;37:658-62.
  12. Racine E, Ji S, Badro V, et al. Living ethics: a stance and its implications in health ethics. Med Health Care Philos. 2024;27(2):137-154.
  13. Vink J. Designing for plurality in democracy by building reflexivity. Pluralist 2022;17(1):52-76.

## Références

1Ray, K. Black Health. New York: Oxford University Press; 2023.

2Statistics Canada. Table 98-10-0337-01: Visible minority by ethnic or cultural origin: Canada, provinces and territories, census metropolitan areas and census agglomerations with parts. 26 Oct 2022.

N, Beranek J, Kennedy M, Onabadejo J, Santos Salas A. Inequities in access to palliative and end-of-life care in the black population in Canada: a scoping review. Int J Equity Health. 2024;23:81.

4Pinault L, Christidis T, Toyib O, Crouse DL. Ethnocultural and socioeconomic disparities in exposure to residential greenness within urban Canada. Health Rep. 2021;32(5):3-14.

5Gupta S, Aitken N. COVID-19 mortality among racialized populations in Canada and its association with income. Statistics Canada Catalogue no. 45-28-0001. 30 Aug 2022.

AN, Ng C, Ellison LF, Seely JM. Breast cancer incidence and mortality, by age, stage and molecular subtypes, by race/ethnicity in Canada. Oncologist. 2024 Nov 2:oyae283.

7Ray K. Black Bioethics and how the failures of the profession paved the way for its existence. Bioethics Today. 6 Aug 2020.

K, Cooper JF. The bioethics of environmental injustice: ethical, legal, and clinical implications of unhealthy environments. Am J Bioeth. 2024;24(3):9-17.

S, Voskes Y, Molewijk B, Widdershoven G. Implementation in bioethics: a plea for a participatory and dialogical approach. Am J Bioeth. 2020;20(4):78-80.

J, Dunn M, Cribb A, editors. Empirical Bioethics. Cambridge: Cambridge University Press; 2017.

MR, Carnevale FA. Moral experience: a framework for bioethics research. J Med Ethics. 2011;37:658-62.

E, Ji S, Badro V, et al. Living ethics: a stance and its implications in health ethics. Med Health Care Philos. 2024;27(2):137-154.

J. Designing for plurality in democracy by building reflexivity. Pluralist 2022;17(1):52-76.