Healthcare interventions — including those that address food insecurity — should examine the multiple layers of a person’s life, rather than simply classifying marginalized groups as “vulnerable,” according to an article published in the AMA Journal of Ethics.1

Alexis K Walker, PhD, and Elizabeth L. Fox, PhD, Hecht-Levi Postdoctoral Fellows at the Berman Institute of Bioethics at Johns Hopkins University in Baltimore, Maryland, argued that clinicians should consider the multiple factors or layers that arise from social marginalization to better target patients in need of special medical and nutritional care.

Drs Walker and Fox reviewed a 2015 paper published in the Journal of Bioethical Inquiry2 penned by Henk ten Have, MD, PhD, of Duquesne University, who contended that bioethical attention to vulnerability emphasizes individuals while ignoring the social connections and forces that form the context of their lives. The term “vulnerability” is often applied to children, adolescent girls, pregnant and lactating women, displaced persons, indigenous groups, and the elderly. Drs Walker and Fox suggested that the term is stigmatizing and that a more nuanced approach can better identify those in need of special consideration.

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The authors reviewed the concept of vulnerability, which is considered a “fundamental bioethical principle.”2 What people are thought to be vulnerable to, however, differs between research and healthcare contexts. When used in the context of clinical medicine or nutrition, the term vulnerability indicates individuals or populations that have inadequate access or lack of engagement.

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The authors used the issue of food insecurity and marginalization to illustrate this. They note that food insecurity is a multilayered problem, the source of which is interconnected economic, social, environmental, and political systems. They give the example of immigrant children who may or may not be food insecure, depending on the community in which they live and their access to well-developed safety nets, social networks, culturally competent healthcare practitioners, transportation, and advocacy organizations. For example, the child of well-educated caregivers who have access to resources and are proficient in the local language is more likely to be food secure than one whose parents are poorly educated, do not speak the local language, and lack documentation.

Drs Walker and Fox feel that giving attention to the layers of marginalization that contribute to food insecurity or poor healthcare encourages clinical settings to become “communities of care.” They contend that those addressing healthcare interventions and food insecurity could profit from considering the multiple layers of an individual’s life that play a role in social marginalization.


  1. Walker AK, Fox EL. Why marginalization, not vulnerability, can best identify people in need of special medical and nutrition care. AMA J Ethics. 2018;20:E941-E947.
  2. ten Have H. Respect for human vulnerability: the emergence of a new principle in bioethics. J Bioeth Inq. 2015;12(3):395-408.