As a couple of people have already pointed out on this blog, "vulnerable populations" seem to have included (under one context or another) every single type of person under the sun except middle-class Caucasian adult males, who, as irony would have it, have probably been made vulnerable by their lack of "vulnerability" because no special health reform agenda will ever be directed at their demographic.
The basic definition given by Meriam-Webster is this: 1) capable of being physically or emotionally wounded; and 2) open to attack or damage.
We can scratch this definition off the list since it is meaningless in the context of healthcare: it includes everyone. That is, it wouldn't make any sense to use the special term "vulnerable population" in health policy discussions if we could actually just say "everyone."
Perhaps there is a more robust bioethical definition. The most consistent one I could find was this:
"Vulnerable populations consist of people at high risk for poor health."
This is a very elegant definition as far as definitions in healthcare go; it is just precise enough to leave plenty of room for interpretation. As beautifully concise as it may be, however, it is also devastatingly complex, to the point of rendering the idea of "vulnerability" virtually useless.
Consider what kind of people are at high risk for poor health.
The first groups that may leap to mind are those that are socioeconomically disadvantaged: the homeless, the addicted, the newly immigrated, and most of all, the poor. These are probably the most often cited because they are the most visible and obvious.
Then there are those who are more susceptible to disease because of their genetic make-up, preexisting health conditions, or age. Some examples include women (who are vulnerable if we consider certain conditions such as pregnancy or illnesses such as ovarian or breast cancer), men (who are vulnerable if we consider certain other conditions such as mid-life crises or testicular cancer), the mentally ill, the physically disabled, the elderly, and children.
But then there are also those that are at high risk for poor health because they lack access to healthcare in another way: they don't have health insurance. It is very important to note that the uninsured population isn't just comprised of those who cannot have insurance, but also those who can have insurance but choose not to regardless. But now we're wandering into murky ethical territory. Interestingly, this is the only kind of ethical territory that exists outside of academic theory. Is not buying insurance (despite having the means to do so) an irresponsible personal choice? Should society at large be held accountable for suffering the consequences of all these bad personal choices?
What about people who drive cars? Surely they're putting themselves at higher risk of being killed than people who sit at home in the corner.
But let's not go just there yet, since we're still not done figuring out what it means to be"vulnerable."
There are also a host of external factors at play. Populations can be made vulnerable not just by their own personal situations or conditions, but also by the healthcare system of which they are a part. A rich suburban community without a single doctor is probably far more vulnerable than a poor rural community with a doctor for every household. Again, vulnerability now becomes a dynamic concept; populations can become more or less vulnerable depending on how many providers settle down and how many leave, how the distribution of specialties changes over time, how many clinics are built or shut down, whether those clinics are 24-hour facilities or only available from 9 to 5, the skill level of the physicians operating those clinics, which in turn depends on the number and caliber of medical schools or residencies available in that region, the quantity and quality of medical equipment available, the pricing of that equipment as well as that of drugs, and so on and so forth until we list every supply-side variable ever studied in public health.
Okay, now let's go back.
There is also a whole other level of "health risk" at play when it comes to social justice. "Vulnerability" can be defined not only in practical or material terms, but also in moral terms. According to Dan Brock (a leading bioethicist), there are those who are put at risk by injustice, those that are put at risk by misfortune, and those who put themselves at risk. That's three seperate tiers of "vulnerability" beyond the categories that we created based on socioeconomic status, health insurance coverage, genetics, availability of providers, quality of healthcare, and so on and so forth. The implication is that these three groups must be treated differently, not necessarily because there is a question of fairness involved, but simply because you cannot solve three different problems stemming from three different causes with the same solution.
I could go on forever (and there have indeed been volumes written about what it means to be "vulnerable"), but let's pause for a second and take a look at the bigger picture.
What is the point of figuring out whether a group of people are vulnerable or not?
I would argue that the ultimate purpose of defining vulnerability is to eliminate it. If we knew how and why certain populations are more vulnerable than others, then we could theoretically level the playing field and make sure that everyone was brought up to an equal standard of care.
I would also argue that it is entirely possible to do this WITHOUT defining vulnerability at all. In fact, the concept of "vulnerability" is extremely damaging to the populations that it is meant to serve because it segregrates them from "the rest of us." It is just another way to fragment an already extremely fragmented system. It pits the AIDS coalitions against the muscular dystrophy groups, the feminists against the advocates for alcoholics, the uninsured against the insured, the middle-class against the lower-class, the cities against the farms. More importantly, however, it is (believe it or not) morally backwards. It is saying that some people deserve more help than others, when in fact healthcare should be indiscriminately, incontrovertably, and blindly available to everyone regardless of just how "vulnerable" they really are. Consider the converses: would you deny a high level of care to someone who was filthy rich and owned half of North America? What about someone who raped and murdered small children? Someone who never paid a cent in his life for health coverage?
The answer is no. Once you start drawing these lines, you can only go downhill. Our only option is to not make the distinction between different kinds of people at all, because even one distinction inevitably sets the precedent for inequality.
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