title: The unjust world problem: Towards an ethics of advocacy for healthcare providers and researchers.
abstract: This article addresses the problem of the relative lack of connection between two ethical perspectives in the healthcare field: an ethics of humane care and an ethics of social justice. The first underlies the critique by practitioners and researchers of differentials between healthcare providers and patients in the irrespective levels of control over communication and collaboration in clinical encounters. The second informs the critique by public health researchers and policy makers of the structural basis of social inequality, poverty, and violence that are the sources of racial, ethnic and class differentials in levels of health. I have framed these two perspectives in a way that suggests their parallel concerns with inequality. By referring to a disconnect between them as the 'unjust world problem', I wish to mark their respective limitations--the first tending to exclude forces that lie outside the clinical situation and the second tending to ignore differentials in access to care and types of treatment received. I argue for the importance of bringing these two perspectives together in a dialectical relationship, where each informs and strengthens the other. Readers of this journal are familiar with studies of communication, clinical practice, and the humane care ethics and, therefore, I highlight studies undertaken within a social justice perspective that document marked disparities among social groups in rates of illness and preventable deaths and also refer to some models of work that link the two perspectives. These are complex issues and by suggesting that we consider an ethics of advocacy that is attentive to both humane care and social justice, I hope to raise questions for further discussion, such as: When we learn to communicate better and to listen to our patients and research subjects, will we be asking about and listening to their accounts of what it means to live in a world of poverty, social exclusion, and inequality? And if we then learn how their problems are rooted in such a world, are we prepared to become advocates with them not only for more humane health care but for social justice?
authors.affiliation: Department of Psychiatry, Harvard Medical School, Cambridge, MA 02139, USA. emishler@attbi.com
authors.forename: Elliot G
authors.initials: EG
authors.lastname: Mishler
mesh_terms: D004992:Ethics, Medical; D014943:Global Health; D006297:Health Services Accessibility; D006801:Humans; D010344:Patient Advocacy / Q000941:ethics*; D011203:Poverty; D011369:Professional-Patient Relations; D011634:Public Health / Q000941:ethics*; D012106:Research; D012935:Social Justice