Moral vulnerability: a view of exclusions in the context of bioethics

This article proposes the discussion of human vulnerability, pointing out that the discussion of social and existential vulnerability is not enough to understand certain situations of discrimination and exclusion to which some people are submitted. It is a theoretical review of the studied subject, with an interdisciplinary approach, as it is used in bioethics. The literature on bioethics already shows the distinction between being vulnerable, an element of human condition and living a situation of specific vulnerability. Being involved in a vulnerable situation indicates the so called ‘social vulnerability’. However, there are situations where the condition of vulnerability of some people is explicitly built from moral, cultural and theoretical elements, that are explicitly espoused and defended. The article approaches the concept of ‘moral vulnerability’ within the framework of bioethics, as a key to understand exclusion and discrimination to which some groups are presently submitted, especially black people, women and homosexuals.


Moral vulnerability: a view of exclusions in the context of bioethics
Nowadays the discussion about vulnerability has a very important space in international bioethical production [1][2][3][4] .In this work, to understand vulnerability as a reading key of human condition takes place from two realities: The first one is that vulnerability is a common condition to all human beings -we are all vulnerable -and this type of vulnerability has been called existential or intrinsic one.The second one is related to groups or individuals who are affected by a circumstantial vulnerability condition, specific, related to poverty, violence, unemployment, among other aspects, being considered social vulnerability.
Those two perceptions have been made explicit in recent productions in bioethics [1][2][3][4] , but this article states that, upon considering the context of denial of human dignity, deprivation of rights, stigmatization and discrimination, the broad concept of vulnerability becomes insufficient.Therefore, we developed the concept of moral vulnerability as ground that helps to unveil human conditions of denial of human dignity in the specific dimension of morale.

Between being vulnerable and currently vulnerable
The vulnerability has been considered an essential anthropological condition of human existence.According to Kottow, for instance, the intrinsic vulnerability to human lives was also acknowledged by political philosophers who proposed social orders destined to protect from violence life, body integrity and property 5 .
In this perspective, it is considered that human beings are vulnerable, as they are under such common condition to everyone, considering their finitude, fragility.But, when the existence is marked by permanent exposure to risks, about which people cannot defend themselves, they are pontentially vulnerable 6 .However, in case of a person, vulnerability goes beyond their biological condition, in other words, it is also disclosed in their existential condition, as they have such great dependency of symbolical symbols and systems, to the extent that they are decisive to their feasibility as creatures 7 .
In addition to such vulnerability, some individuals and groups are directly affected by unfavorable circumstances, where poverty, lack of education, geographic difficulties, chronic diseases, violence and other misfortunes make them even more vulnerable.In this regard, Macklin states that usually people in such condition are relatively or absolutely incapable of protecting their own interests.In a more formal way, they can have insufficient power, intelligence, education, resources and strength or required attributes to protect their interests.Such definition, in the author`s perception, considers vulnerability as a limited capacity or freedom 8 .
To identify the vulnerability process that makes vulnerable people become "vulnerated" 9 is the first step to prevent they go from the condition of being vulnerable to the situation of currently being vulnerable, which requires a broad comprehension about instances and factors, such as State, community, economic and social systems, culture and the own morale in effect in the context where vulnerability is expressed.All those factors can place the individual or group in a situation of concrete vulnerability.Thus, from the scientific point of view, the comprehension about vulnerability process requires an interdisciplinary effort among different areas, including health, social and human sciences.
Considering those contextual aspects, Hans-Martin Sass 10 talks about a "new vulnerability" of modern societies, represented by the easy disruption of interpersonal relationships, unsafety in labor, unequal structure in system of care and its anonymous character, lack of family support in disease and dementia, etc.In this regard, people are under different vulnerability dimensions.For instance, many single people in great metropolis have dimensions of civil freedom that were unknown to pre modern cultures, but they are vulnerable due to absence of community ties that support them.
Upon reading Stepke and Drumond, there are three fundamental axis over which it must be elaborated the vulnerability varieties (felt, attributed or objective): Thus, there is a vulnerability felt or observed by the own subject or group, a vulnerability attributed by others and an "objective" vulnerability about which there is full and universal consensus 11.In other words, upon considering vulnerability as reading key in bioethics, it is fundamental to take into consideration the one that is felt by the own subject, the labeled one, in other words, of who speaks and the objective, actual.The one felt or noticed by the vulnerable person may not be correlative or equivalent to the one attributed by others.Bioethics is in charge of, upon constituting an objective vulnerability, considering the subject who considers himself susceptible, who talks about this subject and the context where he is included, which can also be a vulnerable context.In this regard, there are vulnerabilities shown in an explicit way, being easy http://dx.doi.org/10.1590/1983-80422018261224

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Moral vulnerability: a view of exclusions in the context of bioethics to observe, in other words, the one that is attributed can be more perceptible.On the other hand, there is the implicit one, not always observed and clear, as it depends on the way it is felt by the own subject.
In summary, to advance in the proposal of this work, it is mentioned: 1) The acknowledgment of vulnerability condition is born from the classical question about "what it means to be human".Therefore, it can be formulated as existential condition, as it is inherent to the own human being; 2) Even a fast analysis of reality makes us see the fact that some people "are" within conditions of greater vulnerability than others.Such condition is related to social-economical dimension and, for this reason, it is understood as "social vulnerability"; 3) In contemporary context, where individuality and moral pluralism are valued, there are different vulnerability perspectives, being important to consider the specificities of cultural dimension related to social and economic ones.Such consideration is required to understand and face the exclusion mechanisms to which some individuals and groups are subject only because they disagree or transgress hegemonic values and moral standards.This is precisely the difference between "social vulnerability" dimensions that will be henceforth called "moral vulnerability".

From social vulnerability to moral vulnerability
In order to approach the difference between social and moral vulnerability, we need to consider the difference between culture and society, which are not antagonically dissociated, but they are not the same either.Although we cannot explore here the complexity of those two concepts, or make explicit the different theoretical approaches about the subject, we used the metaphor proposed by DaMatta of conducting a theater play: I think that the text is a metaphor of culture (…) and the society is the plan represented by theater spectacle in its dramatic and scenic practice 12 .Thus, culture is more connected to theoretical and ideal, and society to practical and factual.This approach of relationship between culture and society does not deny the dynamics of reality, where culture influences and is influenced by social practices.It is in this context that is presented the reflection about ethos -considered as moral, esthetic and evaluative elements of a given culture 7 .In pluralist societies, such definition is complex, as it gathers different cultures, knowledge, religions, political perspectives, etc.Then, we can say that there is a predominant ethos in those societies, but never exclusive, hegemonic, absolute.
There are already well-defined realities by culture -within theoretical and ideal scope -that are not easily set out in social dimension.Therefore, there are specifically social problems to which the difficulties are practical, not theoretical ones.For instance, nowadays there is a broad consensus in Brazilian society that each child has the right to full health coverage.But many health professionals are forced to leave children without the desirable assistance due to practical imperative of lack of required resources.
There are situations presented as problems, exactly due to strong cultural elements forged by a worldview that helps to shape ethos.There are also social problems, in the sense that they are real, but actually occur due to culture, dominant worldview that shapes reality.For instance, women recur to health care to treat the consequences of clandestine abortion and such services are denied to them or provided in a precarious way since they are morally classified as "abortive".At the same time, health professionals who assist women in "legal abortion" services, in other words, in cases allowed by law, also claim to be stigmatized among their peers 13 .Thus, it is observed that vulnerability is not necessarily related to social-economic conditions, but essentially to a morale dimension that is irrespective of material conditions of women or health professionals.In order to make explicit those situations we propose the distinction between social and moral vulnerability.
In summary, the social dimension does not enable to understand all mechanisms to exclude people and groups.Therefore, we approached the "moral vulnerability" concept to make explicit the situations where people are excluded due to cultural arguments, in other words, theoretically defendedoften proposed by well-known authors, even if they are understood as part of no dominant ethos and do not represent the hegemonic group in plural society.Thus, it is required to observe better the social vulnerability mechanisms, to make explicit what we consider moral vulnerability.

Social vulnerability
To identify the social vulnerability means, among other things, to understand the subject, his group and State policies.When vulnerable groups http://dx.doi.org/10.1590/1983-80422018261224

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Moral vulnerability: a view of exclusions in the context of bioethics are identified, it must be understood that subjects of a group are not treated in the same way and are subject to different types of vulnerability.Thus, it is possible to consider here the condition of each individual of a group and particularly the influence of social conditioners and routines of their lives 14 .This is because, even if an entire group is vulnerable, this condition is demonstrated in a different way among the subjects.To identify and recognize the way each subject is affected by vulnerability is a great challenge to bioethics.
The social vulnerability requires governmental action through adequate public policies, as when groups are socially vulnerated, there is an explicit violation of human rights defined and confirmed by arguments and international rules 15 .Thus, handling social vulnerability means a specific approach to geographic-political matters.
In the context of bioethics, it was in VI World Congress of Bioethics (2002) where was disclosed in the discussions the necessity of bioethics incorporating in its reflection and action field current political themes, especially social and economic inequalities between rich and poor countries.Garrafa and Porto 16 summarized this approach in the so-called "bioethics of intervention", which proposes that this field handles some persistent problems typical of peripheral countries, such as social exclusion, concentration of power and negative effects of globalization.
In this scenery, the meaning of social vulnerability leads to context of fragility, no protection, debility, deprivation, including abandonment, considering the different types of social exclusion, including inaccessibility to benefits provided by development 16,17 .
Consequently, it is undeniable that the concept of social vulnerability is crucial to bioethics, as it unveils the unfair reality, where people and groups are excluded from social programs and policies, especially owing to the way of economic and political organization.But, as we have mentioned, there are some specific types of exclusion that reinforce fragilities and are not related to merely social-economic conditions.

Specificities of moral vulnerability
The word "moral" is used here as a vulnerability adjective, as it implies that a certain worldview proposes an ethos and, from it, people and groups that agree with such perspective can develop a "moral" evaluation of behaviors, situations or people that are out of such standard.
It is required to highlight that the aspects that contribute to form a "worldview" are multiplescultural, religious, philosophical, scientific, among others, so that "moral" classification is also made from arguments that are clearly explicit, in other words, they are theoretically and formally presented in refined ideological outlines.We used, in such understanding, the word "ideology" as a system of thought that defends social interests, even though we are aware that it became itself, totally ideological 18 .
From the concept of "moral vulnerability" it is possible to clarify the situation of exclusion and discrimination of people in the name of a certain ethos.Such people or social groups, morally fragile, are put in such condition from clear, theoretical arguments that are elaborated from a certain cultural tradition, not rarely with wide philosophical, theological and scientific ground.This vulnerability type challenges bioethics to be critically positioned towards all theoretical trends that devalue the integrality of human being and focus on complex factors that build our worldview, from which the perspectives are built.
It is required to approach the problematic of moral itself, as approaching the dimension of morale in the discussion about vulnerability is considered a central matter in human life.This is because it is out of question to know if a certain morale is real or knowing which is the moral truth or the real moral rule.A fact is imposed to us: People admit a moral rule, believe it and it does not matter if they reflected about it or not 19 . 20.Thus, the field of morale is indispensable to human life.After all, can a person live without habits, costumes, uses and traditions?Therefore, handling morale means considering all diversity of circumstances where subjects and groups are included.

The disapproval stigmatizes individuals and groups and always comes from the ethos which is considered ideal model, as morale handles the real practice of people who express themselves through costumes, habits and values that are culturally set out. A person is moral when he acts according to established costumes and values
To Correa 21 , the individual identity really depends on social and cultural identity.The authenticity is seen in current society as respect to difference, diversity and also multiculturalism.In social plan, the individual identities are formed http://dx.doi.org/10.1590/1983-80422018261224

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upon an open dialogue between everyone and not acknowledging it is seen as a type of oppression.Thus, oppression, intolerance, stigmatization and exclusion disclose the moral vulnerability to which certain individuals and groups are subject for not being acknowledged and accepted by those who share the standard morale.Due to current moral pluralism, such matter becomes more complex, as an individual can be discriminated by his own group for not fitting into the morale rules defined there or he can be discriminated by other social groups that do not accept the worldview of the group to which he belongs.
The morally vulnerable suffer the greatest injustice, as they were put into such conditions due to cultural, social or psychological factors, in other words, suffering negative discrimination and exclusion.Recovering the words of Correa, to be negatively discriminated means to be associated to a destiny grounded on a characteristic that is not chosen, but it is attributed as a stigma.The negative discrimination is the instrumentation of alterity, constituted in favor of exclusion 22 .
In summary, it is considered that moral vulnerability reaches individuals and groups who do not correspond to expected morale and generate negative repercussions, such as exclusion, detachment, segregation and other types of stigmatization and negative discrimination.They are groups who often, in addition to explicit social vulnerability, are also morally judged, sometimes in a masked way and in imperceptible situations which, consequently, are not considered by the different protection and intervention agencies.

The morally vulnerable
In a pluralist society defending that "where there is a human being, there is a full human being" must be an argument of strong humanitarian appeal.One of constitutive elements of ethos of such society must be the acknowledgment of human dignity in its maximum extent and comprehension, valuing human life in all its stages, in all cultural and religious expressions and in all identities.
However, what is observed in contemporary society, permeated by market mode of production and excluding organization, is the opposite movement to which it is not enough that a human being exists.Such hegemonic context imposes that, in order to be acknowledged, people must list their attributes to prove their price, usefulness or adherence to predominant model.
Our society still excludes traditionally discriminated groups, and the morally vulnerable throughout history are still in the same situation.Such dynamics can be understood as follows: Whenever we accept that a human being is more valuable than another one, we find out the ideological process of power relationships that proclaim occasional truths, in a mental scheme that is repeated throughout history: Human "A" who is in power lists his own attributes and conditions as criterion to prove that another one, human "B" is inferior to him, exactly for not having the same attributes and conditions (…) This means to say that 'A' is: 1) The "noble" one, the one who has the objective attribute of having been born from another "noble" and strength to constitute the aristocracy; 2) The "free" who, for having won the war, can elaborate the legal grounds of slavery; 3) The "white" one who got to socially forge the concept of race; 4) "Man", for being male and transform his own strength in ground of patriarchy; 5) The "civilized" (namely, European) who got to use social sciences and prepare the theory of cultural evolutionism; 6) The "rich", who being in condition of using more resources, invented the concept of class grounded on the premise that the one who has more money is more valuable (…).All those "A" humans attribute to themselves a superior value to "B" humans: The plebeian, slave, black, woman, native, poor 23 .
From such considerations, the concept of moral vulnerability helps us to understand that some groups and people have been discriminated in the name of -and due to -the dominant model.And even with the appearance of international agencies that set out and foster human rights, it is perpetuated in our days almost all situations of moral vulnerability reported in history.Even worse, they are still defined and theoretically and formally defended, in other words, as constitutive part of ethos of societies.
The phenomenon of traffic and slavery of people, which still persists, especially in relationships of forced labor and sexual exploitation, are examples of this dynamics.There was certainly a great advancement within international laws, as we seldom see legislations that are explicitly slavery and traffic of people is widely fought.Such situation is clearly included in the analysis that cultural change is slower than legislative development and, thus, a new legislation does not mean an automatic change of ethos of societies.Therefore, the wide philosophical and theological apparatus of the past which justified http://dx.doi.org/10.1590/1983-80422018261224

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Moral vulnerability: a view of exclusions in the context of bioethics slavery remains in the worldview of all those who are still interested to foster such practice.
It is not possible to exhaustively list in this article the situations of moral vulnerability, but we would like to call attention to the fact that events related to gender matter not only repeat discriminatory situations that are historically known, but they also renew themselves and have new artifices, not less cruel and inhumane.Women still suffer violence and discrimination solely resulting from their condition, a situation clearly characterized by what we called here moral vulnerability, as it comes from an extensive theoretical and evaluative ground.
To observe how such vulnerability is reproduced throughout history it is enough to remember some facts: a) The classical Greek philosophy already presented women as not fully rational and Greek societies denied them any civil rights; b) The Catholic Church elaborated the genesis of doctrine, destining to women the role of villain in expulsion of people from Eden.Therefore, women would have a lower place in family hierarchy and would have to give birth in pain to compensate their mistake; c) Some Christianity sectors exclude women from leadership positions, based on a broaden doctrine ground; d) Psychoanalytical theories that consider women incomplete; e) Muslin sectors which define that witness of women do not have the same importance of men; f) Political sectors that oppose to any advancement in women's rights and set out mechanisms that keep the exclusion of women, not due to social-economic conditions, but due to negative valuation and hierarchical of hegemonic morale; g) The laws of many countries that prevent women from studying, having a job and properties 24 .
With regard to sexuality and gender matter, there is an equally important problem: Homophobia.In contemporaneity, homosexuals are one of groups that are most included in the condition of moral vulnerability.Namely, for having a sexual identity not considered "normal" to standards of dominant ethos, they have been attacked, killed, discriminated and excluded.All with broad theoretical, normative and even legislative ground which exclude same-sex marriages from the concept of family, which causes serious consequences for those people.
Finally, the expressions of moral vulnerability, as exemplified, cause problems whose comprehension and facing require consideration of historical, social, economic, political, sanitary, cultural, religious, phenomena, in other words, a broad interdisciplinary approach, which we approached in this work from a bioethical perspective.

Final considerations
It is important to highlight that vulnerability can be classified in, at least three types: Existential, social and moral.
The existential one comes from the fragility condition inherent to human existence, each human being and the planet itself.It would be equally relevant to study the vulnerability of other beings and the environment.Within human reality, the situations of existential vulnerability are marked by suffering, disease and death.Therefore, the human being handles matters of meaning of life, with philosophical and religious appeal.Such vulnerability has a smaller ethical implication, as human action feels limited and often without power to act and mitigate such situations.
Everyone, regardless of social condition, experience this condition.Many people involved in situations of existential vulnerability provoke reactions of compassion and solidarity.In this case, the reflection in bioethics is placed in the necessary care, adequate handling of information, respect to autonomy of involved ones and preoccupation with the defense of integral dignity of the person.
The social vulnerability results from political and economic structures not rarely built by an unfair historical process that cumulatively directs favors and privileges to certain groups, denying them to other social groups.Upon social vulnerability, the human being faces social injustice with strong economical, ideological implications and appeal to political engagement.It is an ethical problem, as it is perpetuated by human structures and can be overcame, but it does not only depend on good will of individuals.
People are exposed to a greater or smaller degree of social vulnerability owing to different factors, from geographic to economic ones.People involved in those situations cause different feelings in others, from disgust of those who want to overcome social inequalities to apathy and indifference of those who do not want or do not see any reason to change the current social situation.An example is the death of a person for lack of economic resources, which becomes more dramatic when it is a child.Education can be a privileged tool to overcome the vulnerability in two senses: Qualifying the fragile subjects and humanizing everyone to seek a fair society and without prejudice.
The moral vulnerability comes from cultural process, which marks the construction of our http://dx.doi.org/10.1590/1983-80422018261224

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worldview and values.To construct the worldview, in addition to social position of people, there are many factors that have a great influence, such as religion, costumes and art.This fragility is more difficult to be observed, as it is fed by beliefs and therefore it is often denied.Upon moral vulnerability the individual faces the cultural different with religious marks, of costumes and traditions.
Such condition is also an ethical problem, but overcoming it is within reach of each person, as it depends on changing the worldview and not only changing social structures.People are exposed to a greater or smaller degree of moral vulnerability owing to different factors: Birth, behavioral, and others.The morally vulnerable are more exposed to embarrassing situations and are target of opposing feelings by others: From engagement of those who want to overcome discriminations to the indifference of many people who justify the situation, to the hate of those who blame the vulnerable people themselves for the situation they are.
It was highlighted in this work as an example of this fragility the violence to which people are exposed due to their gender.Facing it can take place legally, by organization in social movements and personal empowerment process.The religions can also play a relevant role to overcome prejudices related to sexual orientation of people and society justifiably gets shocked with the sexual discrimination by people who manipulate religious concepts.
The non-exhaustive classification of vulnerability in categories approached in this work can assist in the analysis of bioethical conflicts and attempting to overcome them.For instance: In a racist society, a black person can be subject to discrimination regardless of his purchase power, showing a moral vulnerability.Overcoming it does only mean a better income distribution, but a cultural transformation and of other sectors that influence the construction of worldview, such as education and religion.Nevertheless, different vulnerability types are often inseparable in concrete situations.
Work produced within the Graduation Program in Bioethics of Pontifical Catholic University of Paraná.