As the covid-19 pandemic continues to progress across the world, the concept of vulnerability echoes throughout various social and political discourses. For example, it became clear early on, that older people, or those with underlying health conditions were more vulnerable to the severe effects of coronavirus. Further, as a recent Lancet editorial argues, those who are socio-economically disadvantaged are also particularly vulnerable in the context of the pandemic, and as a result of our public health responses.  

From the perspective of ethics, it is important not just to recognise various kinds vulnerabilities, but to delineate them in a way that clarifies the nature and scope of associated moral responsibilities. We must enquire how people have become vulnerable, or are made vulnerable; who and what contributes to creating and exacerbating certain vulnerabilities; and who should contribute to alleviating or preventing them. Vulnerability has had a long—at times, fraught—history in bioethics. The concept has a strong normative pull, in that it engages our moral attention and urges us to action. Equally, as a moral concept, its scope has been questioned, as being both too narrow and too wide. [1] Depending on its conceptualisation however, the term might only encompass very specific individuals and groups, and leave many out of our moral horizon, who would otherwise deserve our ethical attention. On the other hand, it runs the risk of labelling entire groups as lacking the ability to govern their own lives, and of encouraging restrictive and protectionist measures.

The current, global crisis encourages us to engage with the complexity of vulnerability, and its relevance to public health emergency ethics and governance. In this article, I use the taxonomy developed by Mackenzie, Rogers and Dodds to illustrate how vulnerability might be further unpacked and contextualised in the era of covid-19. [2] The following ways to describe vulnerability are not mutually exclusive, and it is likely that one category of vulnerability will interact with, and exacerbate others.  

According to the proposed taxonomy, sources of vulnerability can be inherent or situational. Inherent vulnerabilities are those we face by virtue of having human bodies. In other words, we are all inherently vulnerable to a coronavirus infection, but some aspects of this vulnerability can be influenced by additional factors such as age. In this case, older age renders a person inherently vulnerable to the coronavirus. However, a lack of protection and additional focus on social care in this context, have made adults in social care (additionally) situationally vulnerable to infection and death. Health and social care workers are also situationally vulnerable, due to the nature of their roles, and proximity to patients. Some however are more vulnerable than others, for example, those who have little or no access to suitable personal protective equipment, or work in otherwise poorly resourced contexts. Finally, of these kinds of vulnerabilities can be dispositional or occurrent. This refers to whether the vulnerability is potential or actual. Many of us are dispositionally vulnerable to income loss during a pandemic, some to a greater extent than others. Many however, have been made redundant or have lost their livelihoods entirely as a result of widespread lockdowns, and are now facing poverty, hunger and homelessness. They are occurrently vulnerable. 

Vulnerability should not automatically be equated with frailty or incapacity, and measures to contain or attend to vulnerability must not come at the cost of silencing those considered vulnerable. Yet, the voices of those who are systematically marginalized have been sorely missing in pandemic planning, response, or policy-making. The forced displacement of millions of workers in India following a countrywide lockdown, is an example of compounded situational vulnerabilities. This also illustrates how measures taken to attenuate the risks of the virus have given rise to what Mackenzie, Rogers, and Dodds have called pathogenic vulnerability. Such vulnerability arises as a result of dysfunctional relationships and systems, or when responses directed at attenuating vulnerabilities create new ones. For example, social distancing measures and isolation have exacerbated mental health issues. They have also exposed women and children facing abuse to further violence by forcing them into lockdown with their abusers. Mental health concerns, risk of abuse, economic and other kinds of precariousness are not the unknown and unintended harms of covid-19. Many vulnerabilities have existed, and have been created by policies and social processes prior to the pandemic. They are also routinely ignored in non-crisis conditions, only to be further amplified and entrenched in the context of emergencies. 

What is important to note here, is not only that individuals and groups are differentially vulnerable, but that the reasons for their vulnerability to harm and suffering are not necessarily directly related to the virus. Many are related to social conditions.  The pandemic does not give rise to racism. People of Asian descent have been made vulnerable to racist attacks and abuse because our social structures have allowed for racism to proliferate. That the impact of covid-19 has been particularly severe on ethnic minority communities and individuals is now well established. However, it has also become clearer that such vulnerability is partly situational, given the overrepresentation of individuals from ethnic minorities as key workers and healthcare professionals, and pathogenic, in that it has roots in structural inequalities, marginalisation as well as racism and discrimination. 

When we speak of attending to vulnerability in times of crises, our moral attention must also focus on differentiating various types and sources of vulnerability. Attention to how vulnerabilities are created and exacerbated must be an inherent aspect of pandemic preparedness and response. This is equally true of planning our lives post-crisis, and eventually, as we build a new normal. Vulnerabilities—and those who have been rendered vulnerable—should be at heart of imagining future systems. Otherwise, we will continue to build societies that fail those they seek to protect.  

Agomoni Ganguli-Mitra is lecturer in bioethics and global health ethics, co-director of the Mason Institute for Medicine, Life Sciences & the Law, and works on the ethics and justice aspects global health emergencies https://www.ghe.law.ed.ac.uk/    Twitter: @GanguliMitra

Competing interests: None declared.

References:

1] Levine C, Faden R, Grady C, Hammerschmidt D, Eckenwiler L, Sugarman J, et al. The limitations of “vulnerability” as a protection for human research participants. Am J Bioethics. 2004;4:44–49

2] Mackenzie C., Rogers W. and Dodds S. (2014) Vulnerability: New Essays in Ethics and Feminist Philosophy, OUP.