“History is unpredictable”

(Russian joke)

One way to view human history, is to separate it into the facts of past events on the one hand (insofar as these are known and agreed upon), which is the task of professional historians, and their ethical and political interpretation on the other, which is really the work of us all. As players kneel before the start of a football game to remind us that black lives matter, a slave trader statue in Bristol is thrown into the sea, or a confederate general statue is removed from a U.S. city square, we see a shift in human consciousness to acknowledgement that the battle against racism is far from over. Each generation learns its history through the lens of the dominant thinking of its own time. Historical research continues to shine new light on past events as hitherto unknown documentary evidence is found, but also new interpretations emerge as a result of ethical insights. Like the effect of fluctuating water levels in a lake or a tidal river, when at low levels, the water surface drops to reveal the debris of the past, often ugly, untidy, human and natural, discarded rubbish or dead trees. Sometimes when the water surface is normal, boats will hit unseen submerged obstacles. So too with human history, like a revolving lighthouse beam, collective human consciousness is drawn back to past events, and the attitudes that form them, and evolved ethical thinking leads to strong visceral objection not just to the events in themselves but also to the political and ideological beliefs that underpinned them. And in this there is a strong generational influence. The two areas where this is perhaps most apparent are race and gender. To many born in the post-World War II era, whilst living through the dismantling of many of the world’s empires, there was still a reassuring narrative that the West was right, that colonialism brought civilization and modernity to those parts of the world but still lived in “primitive” conditions. Primitive not understood in the sense of being first civilizations but simply societies that lagged behind the Western industrial revolution. There was also an ethical underpinning that emerged from what must surely be a distorted understanding of Christian teaching, namely that converting the world would enlighten all human beings and guide them to a common way of being. Unfortunately, this narrative was underpinned by an unwavering belief in the superiority of Western Christian culture, a callous disregard for other belief systems and their social structures, traditions, and beliefs, coupled with Western capitalism, enabling a view of the natural world and the indigenous peoples that lived there as both inferior and fair game for the grinding wheels of progress. The early settlers in North America, South America, Africa, Australia, and many other parts of the globe, would have had no idea on their arrival in these vast, and seemingly untouched places, that within a few generations the landscape and natural resources would have been plundered to an extent where the climate and survival of the planet would be in question. It also would not have occurred to them that the peoples who lived there first would have anything to teach them.

So it is that in the second decade of the twenty-first century, new younger generations, with the lake at low water level or the riverbank at low tide, see the debris of the past, that has been ignored for so long, and object. Statues are torn down, and it becomes increasingly difficult to know whether any historical monument can continue to stand when the history behind them is truly examined through a contemporary lens that rejects racism, sexism, and war. It is for this reason that the Black Lives Matter movement and a recalling to consciousness of the horrors of slavery captured world attention again shortly before the enormous destruction of the COVID-19 pandemic. With all due respect to those who fought to abolish slavery at the time, it seems that the memorialization of perpetrators and the historical economic advantages that colonial powers gained from it have still to be atoned for.

In this edition of the Journal of Bioethical Inquiry, we are pleased to publish a symposium entitled “Institutional Racism, Whiteness, and Bioethics” on the historical dominance of whiteness and its all-pervasive but often unseen and unacknowledged influence on various aspects of bioethics. In their lead essay, “Institutional Racism, Whiteness, and the Role of Critical Bioethics,” Mayes et al. (2021) appeal for a deep examination of the dominance of whiteness in bioethics itself: “to address institutional racism, and the compounding problem of whiteness, we need a bioethics that is reflexive and critical of whiteness and its relationship with institutional racism” (¶3). They posed the authors three questions concerning bioethics itself and ways that it might see itself as engulfed in the problem, rather than assuming that it is above looking down from a moral high ground to which, upon deeper examination, it is not entitled.

Yolonda Yvette Wilson (2021) confronts the U.S. healthcare system with “contempt” for people of colour and urges bioethics to adopt antiracism as a core mission. Belinda Borell (2021) from New Zealand examines control of emotions when white and Maori people face death and loss, how the stoical white tradition contrasts with the more open customs and rituals of Maori, and then how this might be a channel to challenge racism itself. Bryan T. Mukandi (2021) offers a “Canaanite reading” of western health systems, contrasting the “seeing” of a doctor and “being seen,” and with images from philosophy and renaissance art, paints a picture of forms of masked racism in everyday health encounters and institutional aversion of the gaze from race issues.

Elias and Paradies (2021) argue that the very legal and social structures of healthcare enshrine racism and perpetuate poorer experiences and outcomes for Indigenous and other ethnic minorities. Heather Came et al. (2021) explore the Matike Mai Aotearoa report on New Zealand constitutional transformation “as a novel means to address structural racism within the health system as a key domain within the constitutional sphere” (“Abstract”), and “assert that constitutional transformation and decolonization are potentially powerful ethical sources of disruption to whiteness and structural racism” (“Abstract”).

Anthony and Blagg (2021) draw attention to the longstanding Australian aboriginal deaths in custody tragedy and focus on a concept of colonial “biopower,” whereby incarcerated first nations people are reduced to mere biological entities, stripped of their rights, dignity, and social traditions. They illustrate this concept with several tragic case histories. Bond et al. (2021) from Australia focus on the need for a reconceptualization of the black body as being both beautiful and belonging “to both someone and somewhere.” Warwick Anderson (2021) considers the history of biomedical research in Australian Indigenous settings. He points out that medical research in Australia has followed a white biomedical model, has a long history of flawed ethics, has mostly failed to involve Aboriginal people in setting priorities and study design, and until very recently, and even now, some remote communities have more genomic sequencing than clean drinking water. In an essay entitled “Race, Reproduction, and Biopolitics,” Christopher Mayes (2021) reviews two books: Catherine Mills’s Biopolitics (2018) and Camisha Russell’s The Assisted Reproduction of Race (2018) and thereby draws attention to the issue of assisted reproduction and the need for ethics and politics to connect and assist in a broader understanding of both race and colonialism, with particular regard to the historical dominance of political liberalism in bioethics at the expense of more collectivist and communitarian traditions in Indigenous and other cultures. Camisha Russell (2021) shows that bioethics can and should assist science to better understand race, again with assisted reproduction as the subject and channel. Truong and Sharif (2021) argue strongly that there is an important role for public health in helping the broader health systems to deal with racism rather than just race per se and that we are actually not “all in this together,” however much (or not) that we may think we are.

In the final essay of the symposium, Tessa Moll (2021) also focuses on assisted reproduction, in South Africa and finds mistrust between patients and providers that lead to racially based disparities in health outcomes.

In the non-symposium collection there are papers on artificial intelligence (AI) in medicine, two on informed consent—one concerning people with low literacy and the other for transgender youth undergoing hormone therapy—and two about aspects of euthanasia.

Nobody in medicine or surgery can afford to be blind or closed to the possibilities of AI. Robotic surgery, for instance, is now widely practiced. But Mark Henderson Arnold (2021) writes that rigorous ethical assessment is needed in tandem with technological advances, to ensure that the humanitarian aspects of medicine are not lost or subverted, with de-humanizing results.

Whilst there is little or no dissent about the need for informed consent, it is clear that it can never be assumed that study participants are truly informed. Despite substantial well-intentioned efforts to make sure that there is true understanding of risks and benefits, Dorothy Helen Boyd et al. (2021) present results of an empirical survey that shows that trust in doctors and desire for a positive outcome were strong motivating factors, and informed consent procedures were not always effective with parents of children in a paediatric dentistry randomized controlled trial.

Clark and Virani (2021) report on a study of minor youth candidates for gender change affirming hormone therapy, finding that most participants showed that they had the understanding and maturity needed and that “granting trans youth with decisional capacity both the right and the legal authority to consent to hormone therapy via the informed consent model of care is ethically justified” (“Abstract”).

Legislation to allow euthanasia, often termed medical assistance in dying (MAD), or similar wording, is gaining ground in a number of countries. In nearly all cases the legislation drafted has an exhaustive procedure, and numerous conditions and exclusions in order to satisfy legislators and ensure passage of the laws. However, it is inevitable that these conditions will be challenged. For those who oppose MAD, these challenges will be seen as evidence for the “slippery slope” arguments that they have repeatedly made, but for the public who support MAD, it will very likely that what might be seen as discriminatory restrictive clauses will be challenged legally and in parliaments. In this issue’s Recent Developments column, Michaela Estelle Okninski (2021) reports on a Canadian case, Truchon and Gladu v Attorney General (Canada) and Attorney General (Quebec), in which the subjective condition of prognosis is challenged. Holzman (2021) reports from the Netherlands on a move by Dutch parliamentarian Pia Dijkstra to allow euthanasia for people who feel that their lives are completed, for whom the prognostic criteria and qualifying medical condition(s) are not met. It is very likely that such moves would have strong support in many countries, but the ethics and law surrounding such claims are contested and divisive and may be impossible to safely enact.

Lastly, there are three responses to papers in the recent JBI symposium on conflict of interest (COI). Michal Pruski (2021) responds to Giubilini and Savulescu (2021) who presented an account of conscientious objection that argues for its recognition as a non-financial conflict of interest and conclude that “conscientious objection should be viewed not as a conflict of interest but as something that society has an interest in preserving” (“Abstract”). Petrini and Riva (2021) respond to Goldberg saying that conscientious objection can inform considerations of conflicts of interest and that relationships will always exist and should not be side-lined in attempts to prevent conflicts. Separate from the symposium but also discussing conscientious objection and value conflicts, Greenblum and Kasperbauer (2021) write to clarify comments about certain values conflicts, made by Bryan Pilkington, about their previous work on what is perhaps somewhat opaquely termed “non-traditional” conscientious objection, where a conscientious objector refuses to be a conduit for the treatment in question (usually abortion) to be performed by another practitioner, and will not, for instance, make the referral.

Looking back at this issue, and so many others, we might well wonder what can be salvaged from the western canon when so much has been done, and continues to be done, to undermine the positives of true liberalism as a political philosophy in the tradition of Mill and others. The centrality of personal agency and freedom, of autonomy and respect for the dignity and needs of each person, is at the heart of most bioethical inquiry. How can the balance be struck with what we learn from older Indigenous traditions, with greater emphasis on collective cooperation, which we all yearn for as well—perhaps the subject of a future symposium? In the meantime, we thank all those who work to shine a torch on racism, sexism, and all forms of discrimination and try to imagine better futures for those who suffer from these injustices, even when it means that the very foundations of our historical assumptions are called into question.

Thank you to all our contributors, Associate Editors, correspondents, and readers around the world who continue to work broadly in the field of bioethics in this time that is so difficult for so many. We have had a number of extension requests from authors, which we have—of course—been happy to grant.