Vulnerability

F Luna, Facultad Latinoamericana de Ciencias Sociales (FLACSO), Buenos Aires, Argentina and National Council of Scientific and Technical
Research (CONICET), Buenos Aires, Argentina
© 2018 Elsevier Inc. All rights reserved.

Introduction

In this entry I will outline some of the philosophical roots of the concept of vulnerability in order to trace how it appears in the
ethical analysis and what conceptual resources the field of ethics has to offer. Thinkers such as Hans Jonas and Robert Goodin
contribute helpful tools in this regard. They provide understandings of vulnerability related to the current human power to affect life
and bio-physical systems on a planetary scale. Lessons can also be learned by looking closely at vulnerability and ethical
responsibility in the area of medical research involving human subjects, for which numerous ethical codes and guidelines have
been developed. I will examine some criticisms and suggest further directions for analysis and debate.

Two Philosophical Approaches

The concept of vulnerability is complex. It embraces different problems in its analysis. In bioethics we can identify at least three
sources of concern: (1) the conceptual analysis (what is vulnerability? what does it mean to be vulnerable?, or how does this concept
function?); (2) the reference and application of this concept (who is vulnerable?: nonhumans, persons, populations, what kind of
population?); and (3) what do the normative implications of this concept generate? (What does vulnerability imply?: special
protection? particular responsibilities?). They different threads of analysis will appear with varying force in the various proposals
I examine.
Presenting all the analyses of the concept of vulnerability—or even the most important ones—goes beyond the scope of this
entry. I will focus instead on two paradigmatic philosophers—Hans Jonas and Robert Goodin. They characterize two diverse
traditions (continental and analytical) that have had a strong impact on the conception and use of “vulnerability” in bioethics, and
their analyses can be extrapolated to broader ecological views.

Hans Jonas, Technology and Responsibility

Hans Jonas, the German thinker, has had a major influence on continental philosophy and European bioethics. The notion of
vulnerability has relevance in his ecological, biological, ethical, and metaphysical thinking. Jonas provides a broad view of
vulnerability with nonanthropocentric features.
Following the German philosophical tradition, his position focuses on the effects of technology. Technological power is not
ethically neutral and should be restricted. He points to a fact of his time (writing in the second half of the XX century):

. . . the critical vulnerability of nature to man’s technological intervention – unsuspected before it began to show itself in damage already done. This
discovery [. . .] alters the very concept of ourselves as a causal agency in the larger scheme of things. It brings to light, through the effects, that the nature
of human action has de facto changed and that an object of an entirely new order – no less than the whole biosphere of the planet – has been added to
what we must be responsible for because of our power over it.
(Jonas, 1984, p. 3)

According to Jonas, modern technological progress endowed humanity with considerable power that, in the long run, risks
altering nature. Troublesome results arise from the human (Luna, 2009, 2014) ordinary employment of technology on a massive
scale. He focuses on collective action and its consequences. These kinds of actions generate cumulative and irreversible effects on the
environment and on the biosphere. He also points out that technology has become the “Calling” of humankind (its employment is
unavoidable) and that it gives rise to crucial ethical issues. The success of modern technology subverts precisely the classical belief in
the invulnerability, immunity, and immutability of nature. This peculiarity of modernity also has an ethical side: since nature is
vulnerable to human action, how can humans be prevented from being overly harmful? Thus, for this thinker, the normative
analysis plays a significant role.
Jonas subscribes to the utilitarian and the deontological point of view, but he also states that these theories are not enough unless
the meaning of nature’s vulnerability is closely understood and explained. Jonas believes that the notion of vulnerability performs a
double function: from a historical point of view, it emphasizes the peculiarity and the fate of Western civilization, while from a
philosophical and methodological point of view, it has a heuristic role. The heuristic function of vulnerability has to do with the
role played by knowledge in morality. Jonas explains:

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128 Vulnerability

The gap between the ability to foretell and the power to act creates a novel moral problem. With the latter so superior to the former, recognition of
ignorance becomes the obverse of the duty to know and thus part of the ethics that must govern the evermore necessary self-policing of our
outsized might.
(Jonas, 1984, pp. 7–8)

For Jonas, predictive knowledge is necessary in order to carry out deeds and responsibly address human power; but whatever
knowledge is acquired will not be commensurate with the overwhelming extent of technological power. To tackle this dilemma
Jonas proposed a heuristic of fear that is closely related to vulnerability. Addressing this point Becchi and Franzini Tibaldeo explain
that Jonas offers the following understanding whose relevance is both theoretical and practical: (a) the biosphere is something at
stake; (b) although only imaginatively anticipated, the possibility that its existence, future, and integrity are in danger is something
tangible; (c) therefore, since “the prophecy of doom is to be given greater heed than the prophecy of bliss,” human deeds ought to
be inspired by responsibility and ought to preserve nature’s existence and integrity (Becchi and Franzini Tibaldeo, 2016, p. 87).
Thus, following these ideas, Jonas’s influence on environmental thinking should be taken into account (Becchi and Franzini
Tibaldeo, 2016, p. 104).
Regarding the applicability and reference of this term, Jonas sustains that the organic world as a whole has to be included in the
domain of responsibility. The biosphere represents a necessary condition of humankind’s own existence. In this way his work
certainly anticipates one understanding of the Anthropocene, namely, that greater human power and influence entails greater moral
responsibility for humankind. For Jonas, responsibility is related to being at the service of and caretaking, and not with dominating
it. He proposes an ethics of responsibility, “an ethics of preservation and prevention and not [one] of progress and perfection”
(Jonas, 1984, p. 139).
In addition to the previous line of thinking, Jonas considers that thanks to modern technology, persons become objects of
technology. Again, following his German tradition, he outlines how modern technology reifies human beings. Jonas exemplifies
how persons become objects of technology with the extension of the lifespan, behavior control, and genetic manipulation. I will
only consider some of these topics in this entry.
Although Jonas recognizes the remarkable achievements of medicine today, he highlights some ambivalence. On the one hand,
it has beneficial effects; it can succeed at preventing serious illnesses and hereditary diseases. On the other hand, medical technology
can distort its ends and turn it into an intrinsically risky and dangerous enterprise. Jonas stresses human life’s fragility and
vulnerability to medical technology and its power. He adds that he fears the erasure of vulnerability, the core of life and human
existence, is no longer considered—but should be. This is why for him an ethical enquiry is urgent. Jonas claims that:

[. . .] each time we thus bypass the human way of dealing with human problems, short-circuiting it by an impersonal mechanism, we have taken away
something from the dignity of personal selfhood and advanced a further step on the road from responsible subjects to programmed behavior systems
[. . .].
(Jonas, 1984, p. 20)

Thus, regarding lifespan extension, he questions its desirability. How desirable is it for the individual and for the species? He
points out that these questions involve the very meaning of our finitude, the attitude toward death, etc. . . . (Jonas, 1984, p. 18). And,
when considering genetic manipulation and biological engineering, he highlights the most serious risks. He asks:

[. . .] this most ambitious dream of homo faber, summed up in the phrase that man will take his own evolution in hand, with the aim of not just
preserving the integrity of the species but of modifying it by improvements of his own design. Whether we have the right to do it, whether we are
qualified for that creative role, is the most serious question that can be posed to man finding himself suddenly in possession of such fateful powers.
Who will be the image-makers, by what standards, and on the basis of what knowledge?
(Jonas, 1984, p. 21)

In this proposal, a conservative and pessimistic view seems to prevail. Thus, though not all technological possibilities that could
be done should be done, a “fear of erasure of vulnerability,” as well as a certain idealization of the “natural,” leads to a strong
mistrust and opposition to technology instead of a more sophisticated way of deciding which relevant technologies to accept and
which to reject.

Goodin and the Protection of the Vulnerable

In line with some of Jonas’s thinking, although taking a completely different tradition and style, the Australian Robert Goodin
argues for the protection of the vulnerable (Goodin, 1985a).
Like Jonas, Goodin centers his analysis on the scope of our responsibilities and on the normative dimension of vulnerability.
Goodin begins with one of our firmest moral intuitions: that we bear greater responsibility for friends and family than for strangers.
The literature refers to this as “special responsibilities.” Goodin argues that our social responsibilities are broader than we might be
inclined to suppose (Goodin, 1985a, p. 12). So, he argues, “There is nothing so very special about the duties to those closest to us, in
fact we owe similar responsibilities toward a much larger and more distant group of persons” (Goodin, 1985a, p. 11). He rejects the
assumption that the moral ground of such responsibility is the moral force of voluntary acts or of “self-assumed responsibility” (the
 Vulnerability 129

obligations we assume by promising, consenting, contracting, etc.). Goodin explains that we do not, for instance, choose our
siblings and yet we are our brother’s keeper. For Goodin, the key factor is the vulnerability of family members to each other—the
radical dependency, say, of an infant on the protection of the parent. Thus, for this author it is the beneficiary’s vulnerability rather
than any voluntary commitment that generates special responsibilities. This reasoning is indeed a quite original way to explain our
responsibilities. And the notion of vulnerability lies at its very core.
Goodin explains his understanding of this concept as follows:

I use ‘vulnerability’ and ‘dependency’ interchangeably to refer to the following situation: A is vulnerable to B if and only if B’s actions and choices have a
great impact on A’s interests. Here I equate ‘interests’ with ‘welfare’ [. . .].
(Goodin, 1985b, p. 779)

For this thinker vulnerability is relational. You are always vulnerable to or dependent upon some individual or group of
individuals who have the power to harm you in some respect(s). And although primary responsibility falls on whomsoever is in the
best (or, in the limiting case, the only) position to protect the vulnerable, that does not relieve others of their responsibility
altogether (Goodin, 1985b, p. 779). They retain what Goodin calls residual responsibility.
Hence, according to Goodin, we bear an obligation to protect all those whose welfare or interests are vulnerable to our acts or
omissions. These obligations vary to the degree in which a person’s welfare is, in fact, dependent on our choices.
Goodin’s work is essentially in the area of ethics with strong consequences on the political philosophy field as he wants to justify
ethically the welfare state. He defends the moral case for the welfare state (public assistance is morally on a par with the aid we
render to family and friends) (Goodin, 1985a, p. 145). He also argues for foreign assistance: denying a needy person assistance
simply because of the color of the passport is as arbitrary as denying assistance because of the color of the person’s skin (Goodin,
1985a, p. 154).
Goodin also argues about our duty to protect the interests of future generations and the environment. So, he says, future
generations are enormously vulnerable to the actions and choices of people today, both individually and especially collectively. The
things we destroy or use up will be unavailable for them to enjoy. Their extraordinary vulnerability to our actions and choices seems
to be the best basis for assigning strong responsibilities to present generations to provide for the future (Goodin, 1985b, p. 782). The
same can be said of animals and the environment:

Dumb animals, delicate coral reefs and ecosystems more generally have proven enormously vulnerable to the actions and choices of human agents [. . .].
(Goodin, 1985b, p. 782)

He reiterates a similar reasoning to the previous although he acknowledges that in this case the question is whether animals and
other nonhuman entities can have genuine interests. He avoids this problem by saying:

It is enough to say that if we see sentient creatures, ecosystems or the natural environments upon which they depend as having ‘interests’ at all, that their
vulnerability will once again generate prima facie responsibilities on our part to protect them.
(Goodin, 1985b, pp. 782–783)

Thus, we may even extrapolate Goodin’s views to climate change and ask if even though no one individual is solely responsible
for the harm being done to others, it is nonetheless a significant example of unchosen moral duty for each of us because it grows out
of the collective consequences of human activity and that those consequences are the basis of moral responsibility.
An important issue Goodin tries to clarify is the need to balance one set of responsibilities with others in light of the criticism that
these responsibilities are incommensurable (the wellbeing of families and friends and our collective responsibilities for social
welfare or the environment). Discharging our responsibilities to one may entail defaulting on our responsibilities to others that are
just as vulnerable as us. He replies that the notion of vulnerability can help resolve these problems and dilemmas. Which we should
favor depends upon the relative vulnerability of each agent. We must determine: (1) how strongly that agent’s interests will be
affected by our alternative actions and choices, and (2) whether or not that agent would be able to find other sources of assistance or
protection should we fail to provide it. Thus, he concludes that it seems likely that those relatively near us in space and in time will
be somewhat more vulnerable. We can show some bias toward our own kind, but that bias must not be absolute. Charity may
indeed begin at home, but morality must not stop there (Goodin, 1985b, p. 783). He admits that his theory is incomplete in the
margins regarding the implication of animals and the natural environment, but he emphasizes that such uncertainty does not relate
to whether they deserve protection but merely to how much they deserve (Goodin, 1985a, p. 188).
Another interesting development of the vulnerability concept in Goodin’s writings is not only the importance he gives to
protecting the vulnerable but to trying to eliminate the conditions that make them vulnerable and dependent. Some of these
conditions may be naturally fixed, inevitable, and immutable. However, most vulnerabilities will ultimately be created, shaped, or
sustained, at least partly, through certain social arrangements. He points out that our moral theories must allow for some inevitable
vulnerabilities and some that are self-selected. Yet, at the same time, we must recognize that such relationships are subject to abuse
and that we must insist on certain conditions to guard against that kind of abuse.
Even though Goodin tries to explain how to solve priorities, it still seems to be an overdemanding theory. Jonas is very much
concerned with technology, while Goodin is more concerned with human relations. So, despite their different traditions, Jonas and
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Goodin do share similar worries regarding the scope of our responsibility. They confer an important role to the notion of
vulnerability and include the biosphere, the environment, and all sentient beings in their account.

Vulnerability in Research Ethics

The concept of vulnerability has had a strong impact and has been widely used and debated in the area of research ethics. The
contemporary British philosopher, Onora O’Neill, presents two interpretations of this concept in bioethics.
Onora O’Neill refers to two quite different ways of conceptualizing the concept of vulnerability. She explains that there are two
dimensions of this word. She acknowledges the continental and existential philosophical tradition and points out that human
beings are persistently vulnerable in ways that are typical of the entire species, requiring protection through justice. She says:

Human beings begin by being persistently vulnerable in ways typical to the whole species: they have a long and helpless infancy and childhood; they
acquire even their most essential physical and social capacities and capabilities with others’ support; they depend on long-term social and emotional
interaction with others; their lives depend on making stable and productive use of the natural and man-made world. [. . .] Protection from injury in the
face of these ubiquitous and foreseeable vulnerabilities of the human condition is in large part the task of justice.
(O’Neill, 1996, p. 192)

Jonas’s thinking appears in this first view. Vulnerability is an expression of the human condition, its fragility and finite character,
and endorses an existential characterization of the term.
But what truly stands out is that O’Neill goes further and explains that human beings may become

deeply, variably, and selectively vulnerable to the action of the particular others and the particular institutions on whom we come to depend for specific
and often unavoidable purposes.
(O’ Neill, 1996, p. 192)

O’Neill considers vulnerability in order to vindicate social virtues and explains why justice is not enough. She explains that just
institutions can aim to avert and mitigate many of the injuries to which characteristic and persistent vulnerabilities lay people open,
but cannot generally avert or mitigate activity that exploits individuals’ more variable and selective vulnerability. And in this second
analysis, Goodin’s theory seems to resonate.
Interestingly, in bioethics, the second dimension of the term gives rise to the idea of “vulnerable groups.” It goes beyond
vulnerability as an “essential” and existential characteristic of human beings. Thus, it does not refer to humanity but—as we will see
in the section “Vulnerable Populations and Codes”—to specific groups or subpopulations that share this characteristic.

The European Conception and the Principle of Vulnerability

As O’Neill pointed out, the continental, philosophical tradition of the concept of vulnerability refers to a universal condition of
humanity. Many bioethicists embrace this first dimension, yet they go even further and consider it a founding principle.
Thus, in European bioethics vulnerability is considered the main principle. The European Commission has identified vulner-
ability as one of the Basic Ethical Principles in Bioethics and Biolaw. This concept plays a key role in European bioethics. Jacob Dahl
Rendtorff and Peter Kemp explain that “the principle of vulnerability is ontologically prior to the other principles (autonomy,
dignity, and integrity). It expresses the finitude of the human condition more clearly than all of the other ethical principles and,
therefore, sustain that it might be the real bridging idea between moral strangers in a pluralistic society” (Rendtorff and Kemp, 2000,
p. 40). In this interplay between principles, the four “American” principles of biomedical ethics proposed by Beauchamp and
Childress (autonomy, nonmaleficence, beneficence, and justice) have been contrasted with the four principles in European
bioethics and biolaw (vulnerability, autonomy, dignity, and integrity). And it is argued that behind the European approach there
is also the biopolitical ambition to propose these principles as a basis for European policies related to human rights (Solbakk, 2011,
p. 90). For Kemp, these principles are not rules for moral conduct but practical valuable aspects of the “good life” (Kemp, 2000, p.
14). The principle of vulnerability recognizes the fragility of an intact but destructible totality and takes into account the biological,
social, and cultural characteristics of human beings living in the modern technological world.
In these analyses the normative aspect is also outlined. Thus, for these authors the scope of “vulnerability” goes beyond that of
being a fundamental or universal human condition; it also seeks to protect life (Rendtorff, 2002, p. 231; Kemp, 2000). This position
is so strong that Rendtorff asserts that respect for vulnerability has to be recognized not only as the most essential principle
of bioethics but also as the basis of all ethics (Rendtorff, 2002, p. 237). Although this position is mainly continental and European,
there are other non-European bioethicists that adhere to this general vision, for example, Hoffmaster (2006) or Callahan (2000).
The concept of vulnerability is articulated in article 8 of UNESCO’s Universal Declaration on Bioethics and Human Rights.
This article states:

In applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account.
Individual and groups of special vulnerability should be protected and the personal integrity of such individuals respected.
(UNESCO, 2005)
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Note the ambiguity of this document: it refers to both the universal vulnerability of the human condition and it singles out
individuals or groups who are especially vulnerable (in the following section we will see how problematic this can be).
Even if the continental view is very ambitious as it is depicted, this principle of vulnerability is not very useful. It may help
describe certain characteristics of human beings but it does not provide the normative force that biolaw or normative ethics seeks.
The authors explain that these principles are not rules for moral conduct but practical valuable aspects of the “good life.” However, it
is not clear how these principles function. Another feature relevant to this entry is that these thinkers settle a trend for an
anthropocentric concept as it depicts vulnerability as a fundamental human characteristic. What European bioethics captures is
an essential human feature. And, as we will see later, the focus on humans is kept and it will be maintained in bioethics even if
different proposals and analyses are introduced.

Vulnerable Populations and Codes

The concept of vulnerability plays a fundamental role in research ethics. When research ethics codes try to characterize vulnerable
persons or vulnerable populations, they take into account Onora O’Neill’s second dimension of vulnerability. Even article 8 of the
UNESCO declaration, as was mentioned previously, refers to vulnerable groups. Codes do not speak of vulnerability as a condition
of humankind but of how certain individuals or groups may become deeply, variably, and selectively vulnerable to the action of the
particular others and the particular institutions. However, as we will see, these proposals are not enough to counter the attacks this
concept faces.
The Belmont Report sets the pattern of this concept. The third part of this document is devoted to the application of the general
principles after proposing and explaining three basic ethical principles of research. The Belmont Report considers three require-
ments: informed consent, risk/benefit assessment, and the selection of research subjects. Vulnerable subjects, groups or populations
are mentioned in all three requirements. For example, when considering informed consent, the Report brings up vulnerability in its
discussion of voluntariness regarding the possibilities of undue inducements. This document recognizes that “inducements that
would ordinarily be acceptable may become undue influences if the subject is especially vulnerable.” Vulnerability also appears in
the section devoted to the evaluation of risk/benefits. When it considers the assessment of the justifiability of research, it explains
that it should reflect some considerations. One of these is the appropriateness of involving vulnerable populations and that such a
decision should be demonstrated (Belmont Report, op. cit. C.2.). Finally, vulnerable individuals are also introduced when it
examines the selection of research subjects. It considers the participation of vulnerable subjects a special case of injustice. And it is
here where the Belmont Report refers to groups such as racial minorities, the economically disadvantaged, the very sick, and the
institutionalized (Belmont Report, op. cit. C.3.). The document states that they may be selected because of their dependent status
and frequently compromised capacity of consent, something that should be protected.
Hence, this first document does not explain “vulnerability.” This document does not offer a criterion to know when it should be
used. It does not state why a person becomes or is vulnerable. “Vulnerability” is mentioned and exemplified just by naming groups
of populations. And the normative dimension is introduced as it calls for protection, but provides no other details.
In the first version of the Declaration of Helsinki and until 1989 there is no reference to vulnerability or vulnerable populations.
Article 8 of the 2000 version, refers to vulnerable populations. It mentions some of the groups previously considered in the Belmont
Report and this trend continues in the subsequent versions. In the International Guidelines for Biomedical Research Involving
Human Subjects in CIOMS-WHO (CIOMS Guidelines) first version, in 1982, vulnerability appears more clearly as an important
issue. It is mentioned in the Background Note, as well as in the commentary of several guidelines, but it does appear explicitly in
Guideline 10. This guideline makes an effort to identify vulnerable persons and groups. However, CIOMS still follows the path set
down by the Belmont Report: it names the same vulnerable population and adds HIV persons. The 2002 version of the CIOMS
guidelines follows the same pattern as its previous version. But what is indeed an interesting addition is the effort to define
vulnerable persons. The first paragraph of the commentary to this guideline says:

Vulnerable persons are those who are relatively (or absolutely) incapable of protecting their own interests. More formally, they may have insufficient
power, intelligence, education, resources, strength or other needed attributes to protect their own interests.
CIOMS Guidelines, 2002 (Guideline 13)

Initial Analyses of the Concept

While ethical codes were reviewed and modified, academic research ethics was examining different analyses regarding the concept of
vulnerability. I will consider only a few articles in research ethics (those that tried to offer a criterion or analysis of the concept).
Philip Nickel’s, for example, links vulnerability to the principles of respect for persons and of fairness. He goes back to the Belmont
Report and argues that there are two overlapping senses of vulnerability in research, which relate to two principles in that report.
He claims that there are consent-based and fairness-based reasons to call a group vulnerable. The first principle is respect for
persons. This principle implies informed consent in research participation. He explains that ordinarily, people safeguard their own
rational interests. When they cannot do so, for example, when their autonomy is diminished, they are entitled to special protections.
This is the case of young children or the mentally ill. Distinctions principles of fairness – commonly labeled principles of “justice” in
bioethics – provide a second source of justification for protecting vulnerable populations. The Belmont Report expresses the need
for scrutiny in light of the fact that “some classes [of persons] (e.g., welfare patients, particular racial and ethnic minorities or persons
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confined to institutions) are being systematically selected simply because of their easy availability, their compromised position or
their manipulability, rather than for reasons directly related to the problem being studied” (Níckel, 2006, p. 247). Nickel explains
why the lack of fairness is one of the sources of justification for protecting vulnerable populations (Níckel, 2006, pp. 247–249). This
author applies his analysis to people with serious illnesses, arguing that they have a susceptibility to “enticing offers” that hold out
the prospect of removing or alleviating illness, and this susceptibility reduces their ability to safeguard their own interests (Níckel,
2006, p. 245). He articulates what the documents have been addressing and acknowledges that vulnerability is the rule rather than
the exception in biomedical research.
In a similar vein, Samia Hurst adds to consent-based, harm-based and comprehensive but finds these three kinds of character-
ization of vulnerability inadequate (Hurst, 2008, p. 192). For her, vulnerability is a claim to a special protection (i.e., the increased
likelihood of incurring additional harm or greater wrong) (Hurst, 2008, p. 195). Macklin, for example, criticizes this position
pointing out it may be difficult to determine when or under what circumstances a claim is valid, and also as being too narrow for
other contexts besides research or clinical ethics (Macklin, 2012).
Zion et al. (2000, p. 615) provide another strategy. They offer an analysis of vulnerability from the perspective of basic rights.
Zion et al. use the notion of “basic rights” in order to identify vulnerable groups. They explain that “Medical research takes place
within a complex web of power relations, in which subjects – particularly subjects who are economically disadvantaged – are easily
exploited” (Zion et al., 2000, p. 615). They note that while the Declaration of Helsinki does not address this, the CIOMS Guidelines
do. This document states that the lack of alternative means of obtaining medical care or other expensive necessities is one
characteristic of the vulnerable to exploitation. They argue that these special groups are vulnerable populations because they lack
basic rights and liberties that make them particularly open to exploitation. They ask for special ethical consideration and rigorous
ethical accountability (Zion et al., 2000, p. 616). Note that Nickel and Zion et al.’s analysis, though considering different strategies,
shares the idea of the importance of the lack of power, the lack of rights which can easily be linked with Goodin’s account of
vulnerability as dependency (Luna, 2009, pp. 126–127).

Problems With the “Traditional” Analysis

While the list of vulnerable populations grew more extensive for reasons of consent, fairness, exploitation, and so on, in 2004
Carole Levine, Ruth Faden, Christine Grady, Dale Hammerschmidt, Lisa Eckenwiller, and Jeremy Sugarman criticized the concept of
vulnerability considering it a useless concept. These authors published an article in the American Journal of Bioethics that had a strong
impact on bioethics scholars. The article revealed the crux of many of the problems that this concept holds. One of their criticisms
said:

Under one or another of these rubrics, nearly everyone is vulnerable, especially since the benefits of research can never be guaranteed in advance [. . .]. If
everyone is vulnerable, then the concept becomes too nebulous to be meaningful.
(Levine et al., 2004, p. 46) (my emphasis)

These authors point out the useless character (for normative proposals) of the existential approach. This existential approach
claims that everyone is vulnerable, fragile, and finite. This argument is valid. I do agree with Levine et al. on this criticism (Luna,
2009, pp. 126–128). On the existential account, vulnerability is a universal human feature, an ontological condition. And while it is
true that everyone is exposed to suffering, deterioration, and death, this is not the relevant point for research ethics. The danger of the
existential and essentialist interpretation of vulnerability is the risk of naturalizing vulnerability: if everyone is equally and essentially
vulnerable, no one is specifically vulnerable. Moreover, no one would need any kind of special protection. This is exactly what critics
of a strong and meaningful account of vulnerability want in research ethics. They seek to annul the normative force of this concept.
“If everyone is vulnerable, then the concept becomes too nebulous to be meaningful.” For this reason, the overly broad use of
vulnerability is dangerous, unless other normative concepts are introduced (disadvantage, injustice, and so on) to protect
vulnerable persons (Luna, 2014, p. 184). A related criticism, these bioethicists point out is that the only advice given is very general
and vague: to pay “special attention” or to give “special consideration” (Levine et al., 2004, p. 46). Thus, research ethics committees
have no guidance.
Another criticism Levine et al. mention:
“. . . the concept of vulnerability stereotypes whole categories of individuals, without distinguishing between individuals in the
group who indeed might have special characteristics that need to be taken into account and those who do not” (Levine et al., 2004,
p. 47). And they add: “the most prevalent questions raised about vulnerability have been whether to add a particular group to
vulnerable category.”
One of their concerns is that while drafters of the Belmont Report and other early US documents “[. . .] were reacting to a series of
specific historical events and groups of research subjects; the recent history of the use of vulnerability is more expansive, particularly
in the international context” (Levine et al., 2004, p. 45). Thus, they feared a growing overpopulation of “new vulnerable groups” in
which “vulnerability” becomes a laxly used label to tag anybody in the research setting. A good example of this lax use is provided by
the Report of the International Bioethics Committee (IBC) of UNESCO (UNESCO, 2013) which tries to flesh out the concept of
special vulnerability highlighted in Article 8 of the Universal Declaration on Bioethics and Human Rights (UNESCO, 2005). The
Report does nominate “female” (adult and children) as an especially vulnerable group. This was strongly criticized. For example,
Mary Rawlinson says, “It is odd to label half of the human race a special class” (Rogers et al., 2012a, p. 8).
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In “Elucidating the concept of vulnerability: layers not labels” (Luna, 2009, p. 127), I agree with the criticism of labeling and
stereotyping that Levine et al. outlined. However, I disagree with their strategy to strongly reject this concept. It implies throwing out
the baby with the bath water. I think we have to distinguish the different concerns pointed out at the beginning of this entry: (1) the
conceptual, (2) the application or reference and (3) the normative concerns. The concept of vulnerability is quite relevant to
research ethics. It has an important normative role and a political force. There are, however, serious conceptual problems (as Levine
et al. stress) that should be solved in order to restore its usefulness and normative force.
Acknowledging the problems of stereotyping and labeling populations as vulnerable, I presented, instead, another approach—
the metaphor of layers (Luna, 2009, pp. 128–133). To explain this I first analyze what I call the traditional or typical approach,
which I find controversial. By focusing on subpopulations, in the case of researchthe traditional analysis does two things: first it
assumes a baseline standard for a default paradigmatic research subject: a mature, moderately well-educated, clear thinking, literate
self-supporting person. Second, it assumes the possibility of identifying vulnerabilities in subpopulations as variations of the
paradigm or as defaults of the paradigm. One problem then is that, as not everyone is comparable in the relevant way, members
may fall outside the defined subgroup (Luna, 2014, p. 184). And another is the idealization and simplification it assumes.
Thus, traditional analyses have tried to define “vulnerable populations” in terms of their necessary and sufficient conditions.
That is, if a person satisfies x and y conditions, he or she belongs to a particular group of people and is therefore, by definition, a
vulnerable subject. This has led to an essentialist and overly rigid view of the concept that categorizes a group as vulnerable. In turn,
this entrenches stereotypes and categories and ignores variation between members of the group (Luna, 2014, p. 184). It provides only a
partial analysis of vulnerability because it does not provide tools to identify or understand variations or situations that may
accentuate or minimize vulnerability. This is not only an undesirable consequence for research ethics but also for public health as
the subpopulation approach leads to a simple and “one-size-fits-all” solution for the subpopulation and is insensitive to
particularities. Therefore, I do agree with most of Levine et al. criticisms.
As shown, Robert Goodin uses vulnerability and dependency interchangeably (Goodin, 1985a; Goodin, 1985b). In bioethics,
Rogers et al. (2012b) explain that more than ordinary vulnerability entails an increased risk of harm. Although with slightly
different emphasis, the previous authors definitions signal dependency, exclusion, increased risk of harm or wrong to the interests,
wellbeing, health, or autonomy of others. However, even though endorsing one of these definitions may help understand who is
vulnerable—that is the reference of this concept, it will not show the richness and particular functioning of this concept. Nor will it
explain why at times we see so many disparate and differing dimensions of vulnerability (i.e., related to consent capabilities, to the
possibility of abuse or exploitation, to the lack of special social support, and so on). In addition to an adequate definition of
vulnerability, we also need a dynamic and contextual analysis that can capture the multifaceted aspects of the concept of
vulnerability. This is the layered approach I defend.
The layered approach “unpacks” the concept of vulnerability and shows how the concept functions. Layers may overlap rendering
the person increasingly more vulnerable. To illustrate, consider the following example:

Being a woman does not in itself entail vulnerability. However, a woman living in a country that does not recognize or is intolerant of reproductive rights
acquires a layer of vulnerability. In turn, an educated and resourceful woman in that same country can overcome some of the consequences of the
intolerance of reproductive rights; however, a poor woman living in a country that is intolerant of reproductive rights acquires another layer of
vulnerability. (She may not have access, for example, to emergency contraceptives and, hence, will be more susceptible to unwanted pregnancies).
Moreover, an illiterate poor woman in a country that is intolerant of reproductive rights acquires still another layer. And, if she is an immigrant,
undocumented, or belongs to an indigenous community, she will acquire increasing layers of vulnerabilities and suffer under these overlapping layers.
(Luna, 2009, pp. 128–129)

Interestingly, this conceptual analysis enables us to move away from the “usual” or “typical” stereotypes. For example, we
generally consider poor, pregnant women vulnerable. However, in certain situations this might not be true. Argentine law allows
poor, pregnant women to collect cord blood if they need it for another child through the public bank or they can donate to the
public bank and the public system will cover the entire process. Yet, the pressure that commercial cord blood banks place on
middle-class pregnant women is so strong (through aggressive marketing in gynecologists’ private offices, misleading information,
guilt on the part of woman for not being a “good mother,” and so on) that it is the middle-class pregnant woman that may become
vulnerable (Luna and Vanderpoel, 2013). It should be aknowledged that as some legislation was passed in 2009, this information is
now is more accurate.
In sum, the subpopulation approach is inadequate because it is tantamount to using the vulnerability concept as a mere slogan,
categorizing and stereotyping persons. It obscures the different dimensions and features of vulnerability.
This layered approach has not only impacted academic bioethics but also an important ethical code like the CIOMS-WHO
Guidelines. Feminist thinkers, such as Rogers et al. (2012a,b), consider a relational approach to autonomy, as well as a layered
account of vulnerability. They integrate different dimensions of this concept: the universal-ontological condition plus the contin-
gent and context specificity of many kinds of vulnerabilities, as well as their origin in social and political structures (rather than in
biological forces). They aim to reconcile vulnerability with autonomy. Thus, in some specific situations vulnerability must be
addressed by offering not only protection and safeguards but also the possibility of empowerment (Rogers et al., 2012b). That is,
not only harms should be minimized but also empowerment and autonomy should be supported. Although they acknowledge the
layered approach to vulnerability, they go beyond and propose a taxonomy. They distinguish different sources of vulnerability:
inherent, situational, and pathogenic. Their account is very interesting, especially their consideration of empowerment. Also,
134 Vulnerability

Macklin considers the layered approach, together with the definition of Hurst (2008). Combining both, Macklin sketches a theory
of vulnerability that can be applied to broader social contexts, such as women in developing countries (Macklin, 2012).
Yet, an even stronger impact is the one that this layered approach has had on ethical guidelines. This is highly relevant because a
proper understanding of this concept could defend it from criticisms and rejections and could serve as a more fitting criterion for
research ethics committees. The second paragraph of the Commentary to Guideline 15 in the current version of the CIOMS
guidelines says:

A traditional approach to vulnerability in research has been to label entire classes of individuals as vulnerable. The account of vulnerability in this
Guideline seeks to avoid considering members of entire classes of individuals as vulnerable. However, it is useful to look at the specific characteristics that
may render individuals vulnerable, as this can aid in identifying the special protections needed for persons who may have, an increased likelihood of
being wronged or of incurring additional harm as participants in research. Different characteristics may also co-exist, making some individuals more
vulnerable than others. This is highly dependent on the context. For example, persons who are illiterate, marginalized by virtue of their social status or
behaviour, or living in an authoritarian environment, may have multiple factors that make them vulnerable.
(CIOMS-WHO, 2016) (my emphasis)

Thus, this document turns from its 2002 version. For the first time a research ethics guideline moves away from the traditional
approach. It leaves the traditional scheme and circumvents the subpopulation approach. Even if the CIOMS guidelines do not use
the word “layer,” the layer metaphor is embedded in this conceptual analysis. CIOMS uses the words “characteristics and factors”
but they play the role of “layers.” It speaks of multiple factors that may render a person vulnerable, as well as different characteristics
coexisting. It also overcomes the vague indication regarding protection and suggests a strategy whereby the research ethics
committees consider specific characteristics as these can help to identify special protections. This was suggested as a method
research ethics committees should consider (Luna, 2009, pp. 129–131). Again, the layered approach to vulnerability prevails.

Final Words

What this conceptual landscape shows is the complexity and richness of the concept of vulnerability and its multiple dimensions.
Thus, we can return to the three sources of concern mentioned in Section I of this entry. They present different angles of the problem.
Regarding the first concern, the conceptual analysis there are several definitions. Some of them point to dependency, exclusion,
rights, increased risk of harm or wrong for the interests, wellbeing, health, or autonomy of others. These multiple ways of defining
vulnerability exhibit this multifaceted aspect of the concept of vulnerability. Yet, instead of focusing so much on definitions, what
seems to be fundamental in order to determine a relevant and applicable concept is the elucidation of the way the concept of
vulnerability functions. Thus, as was shown in the last section, we should move away from mere slogans or labels. We should avoid
the rigidity of stereotypes and work instead with the metaphor of layers. It will enable us to consider the context in a relevant way
and will provide a meaningful analysis for research ethics or public health ethics. Moreover, if we consider the impact of climate
change on health or another bio-physical system disruption, we will need to conduct serious research on these issues and will have
to consider different layers of vulnerability that arise in those affected. We will have to consider the context, its modifications and
dynamism.
Regarding the second concern—the reference or application—we can easily see how bioethics (especially research ethics and
public health ethics) has focused mostly on humans and, depending on whether we accept a traditional or subpopulation
approach, whom we qualify as vulnerable will vary. However, analyses, such as those of Jonas and Goodin, expand the scope of
vulnerability and include the biosphere, the environment, and so on. They show how fragile ecosystems are and how nonhumans
are just as vulnerable.
While Jonas focuses on technology, collective human power and possible misuses of it, Goodin points to the radical dependency
of the vulnerable, which leads us to the third source of concern—the normative implications of the concept of vulnerability. Both
philosophers seriously consider our responsibilities and our obligations toward the vulnerable. Interestingly, in research ethics the
political relevance of this concept emerges. We cannot lose this concept because its allegation is crucial. It will safeguard adequate
protections. Attributing a layer of vulnerability raises the normative commitment to relevant protections (minimizing, reducing, or
eliminating that layer) or to empowering the vulnerable in order to reject such a possibility.
Given the above, the concept of vulnerability cannot be treated as a simple trait of beings or as a slogan. As was shown, the
concept of vulnerability exhibits multiple facets and may present various nuances depending on the different authors and academic
analyses. It is a crucial concept and we are likely to see new conceptualizations of it, for example, in the light of an earth system
perspective and impending ecological conditions.

References
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Further Reading
Council for International Organizations for Medical Sciences (CIOMS) and World Health Organization (WHO). 1993 (1st edn.), 2002 (2nd edn.), 2016 (3rd edn.). International ethical
guidelines for biomedical research involving human subjects. Geneva: CIOMS.
Council for International Organizations for Medical Sciences (CIOMS) and World Health Organization (WHO) (2002) International ethical guidelines for biomedical research involving
human subjects, 2nd edn. Geneva: CIOMS.
Luna F (2015) Rubens, corsets and taxonomies: a response to Meek Lange, Rogers and Dodds. Bioethics 26(6): 448–450.
National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report. Available at the US Department of Health and Human Services
Website, http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.htm, original report published 1979.C1.
Ruof M (2004) Vulnerability, vulnerable populations, and policy. Kennedy Institute of Ethics Journal 14: 411–425 (Scope Note 44).
World Medical Association, Declaration of Helsinki (2000). Available from http://www.wma.net/en/30publications/10policies/b3/.