Pediatric Bioethics: New Insights into Vulnerability

Column Author: Brian S. Carter, MD | Neonatal/Perinatal Medicine, Bioethics; Interim Director, Pediatric Bioethics

Column Editor: Amita Amonker, MD, FAAP | Pediatric Hospitalist | Assistant Professor of Pediatrics, UMKC School of Medicine 

“Vulnerability” is so loaded with political, moral, and practical implications that it is potentially damaging to the pursuit of social justice.

Kate Brown, PhD, “‘Vulnerability’: Handle with Care”

The practice of pediatric medicine and surgery is permeated by the reality that children of all ages represent a group characterized by vulnerability. This reality has ethical significance. Not only is it inherent in the ascertainment of exposing vulnerable populations such as children to risk in research, but it also characterizes the child – an individual with great potential but who requires time, guidance, nurturing, protection and the provision of basic needs such as food, clothing, shelter, education and health care.

But let’s look deeper into vulnerability. What does it mean to be vulnerable? In many instances we tend to “label” those who are vulnerable due to characteristic external risk factors. To name a few, consider those negatively impacted by social determinants of health (deprivation from food deserts, poor environmental health from exposure to secondhand smoke, air pollution, or proximity to industrial sites); inequities in access to health care – perhaps due to lack of transportation, racism or poverty – which lead to inequities in options available to them; and the consequences of inequities in options provided to them – limited choices, constrained autonomy and freedom. With inequities in options come inequities in treatments, which are followed by inequities in outcomes.

To revisit vulnerability, we must accept that we will be challenged to see and think differently, ethically, about one another. Such new considerations may bring about greater and more equitable care as they can inform our dealings with the inherent tensions between individual liberty and societal justice. I see this as an invitation to attempt to address matters of power differentials, public health priorities, and even politics. Turning away from these often negative frames and influences, attending to vulnerability may inform how intent we are upon improving communication, considering varied perspectives, and collaborating in efforts to mitigate those conditions contributing to vulnerability and work in an engaged manner with the communities we serve. Collaboration, built through impeccable communication, transparency, and building trust, will both inform and help actualize shared decision-making.

We are all vulnerable. The Latin word vulnus (wound) is the root of the word vulnerable. And we all have been, or can be, wounded in one way or another. In a sense, we all live with our own trauma histories. Admittedly, these are not all physical traumas such as those brought about by war, crime, famine and natural disasters. They include emotional wounds, our variable capacity to contend with emotional matters – what we call our coping mechanisms – and how we can adjust and move forward. For clinicians, leaders and executives, there are also cognitive vulnerabilities. Amid the ever-present constraints of uncertainty (and the variability in how we contend with it), ambiguity in outcomes and the value ascribed to them, and even how we think we know (in philosophy what is referred to as epistemology – the theory of knowledge and the investigation of what distinguishes justified belief from mere opinion), we must make decisions and act. Acknowledging our own cognitive vulnerabilities, varied coping skills, the imperfections in our societal structures and ordering of priorities, let’s embrace our own vulnerability and move forward to consider how we can serve others to attain better health in a better world for all children within all families.