Some barriers to knowledge from the global south: commentary to Pratt and de Vries

Pratt and de Vries pose an important and uncomfortable question to all stakeholders in the global bioethics space. If global bioethics as they define it is ‘the ethics of public health and healthcare problems that are characterised by a global level effect or that require action beyond individual countries, and the ethics of research related to such problems’, one would expect justice and inclusivity to be among the ethical priorities. Yet, Pratt and de Vries carefully demonstrate how different forms of epistemic injustice and coloniality are embedded in the structure, generation of knowledge and praxis of global bioethics. They do this by unpicking three layers at which coloniality and epistemic injustice operate; knowledgeproducer, knowledgeapplied and knowledgesolicited. The authors also offer a threepronged incremental approach to how individual and institutional actors in global bioethics can contribute to epistemic justice in the field. Pratt and de Vries present their work as ‘a first step towards reorienting the field’ of global health bioethics away from epistemic injustice. Indeed, theirs is a mapping, problem statement and recommendations piece that will be useful for future conversations on epistemic justice in global bioethics. My commentary is not so much a critique of the meticulous work done by Pratt and de Vries, but an attempt to highlight key structural barriers that need to be addressed if knowledge from the global South is to be given a fair space within global bioethics. I will do this following the threelayered structure proposed by the Authors and conclude by offering a conceptual suggestion that broadly encompasses the pathways suggested by the Authors for increasing epistemic justice in global bioethics. In the unpacking of the knowledgeproducer layer—who is producing knowledge in bioethics—a key actor is the university institution. A 2023 critique of the conceptual flaws and colonialitybiased university ranking criteria by NassiriAnsari and McCoy shows that the top 20 ranked public health study programmes are all in the global North. They argue, based on empirical data that university ranking systems are designed to reinforce the concentration of power and prestige among universities in the global North. Universities are among the principal knowledge producers in global health. Thus, rethinking how we classify and rank knowledge producers is an important step toward epistemic justice within the knowledge producer layer. When we consider the knowledgeapplied layer—what theories and concepts are being applied to produce ethics knowledge—Pratt and de Vries call for the inclusion of epistemologies and ethical frameworks from the global South in education and praxis. Here too, it would be important to consider that, as pointed out by Cloartre, the Law has been systemically used to ‘other’ nonbiomedical ways of conceiving health and practicing healthcare. A thorough inclusion of global South epistemologies in healthcare and bioethics would require a legal framework that avoids putting ‘nonstandard’ conceptualizations on the backfoot or even worse, considering them as ‘alternative’ or complementary. And finally, on the knowledgesolicited layer,—whose voices are sought, recorded and used to generate ethics knowledge—while much progress has been made in recent times to include representation from the global South in international organizations, what remains to be seen is how these representatives are selected. Is the selection of these global South representatives based on their capacities to understand and propagate the ideas emanating from the global North or are they capable of shifting the existing conversations by introducing global South views and epistemologies into global conversations? Pratt and de Vries suggest that the way forward is a threestep approach of understanding the problem, engaging in dialogue, and implementing structural change. These, in my view, can be captured under subsidiarity, a notion that has not been sufficiently explored in the global health governance space. The specific moral wrong of colonialism can be traced to the subtraction of agency of peoples and communities while reorienting all agency towards the interests of the colonizers. From this viewpoint, subsidiarity is both a principle of decolonization and justice because it insists on a bottomup approach to governing multilayered structures in a way that the agency of local organizations, usually closest to the issues at stake, is given space, and assisted—subsidium—to be able to resolve the issues that are within their capabilities. Global North bioethicists, rather than seeking to find universal solutions to global health issues, would do better by assisting and empowering local bioethicists to find solutions to their problems. This approach is quite different from the multiple capacitybuilding initiatives that often entrench epistemic injustice and coloniality by acritically transferring global northern knowledge systems and epistemologies to the global South. The way forward for global health bioethics is arguably pluriversality and deimperialisation. Where pluriversality recognises that there is not a single, but multiple ways of knowing and understanding and deimperialisation requires a departure from the assumptions of cultural superiority to a humbler position of seeing others, although economically poorer others, as equals. Pratt and de Vries have offered the global bioethics community a key and a framework that can stimulate further conversations, but above all, transformations, in global health bioethics.