When I say … social justice

Abstract

We live in a world where many people have to hide who they are. In Robinson's “A Portable Paradise,” he writes about his experiences as a Black British man and of how he has to hide and protect his “paradise.” He cautiously conceals beautiful memories of Trinidad so that the harsh social landscape of Britain, which actively seeks to “steal” his “paradise,” cannot.

Robinson's powerful poem left each of us with a deep feeling of social injustice, but seemingly through different perspectives. We are all medical educators, and yet, we had diverse understandings of “justice” and found difficulty in articulating the origin of our views, somewhat surprisingly. * Together, we reflected on varied understandings of social justice, including the oppression faced by minoritised learners, and how, in our experience, our field remains focussed on describing problems, rather than creating change. We discussed our approaches to inclusive curricula and, critically, the dominance of Western understandings which have assumed global applicability.

Interested in understanding the multiplicity of our views and in finding a common language through which we could share learning, we embarked on this article to untangle the meaning of social justice, finding an absence of a cohesive definition focussed on the practice of medical education. By this, we mean that existing definitions often fail to address the practical aspects of how social justice can be applied and integrated within medical education.

In this article, we translate key theory relating to social justice to the context of medical education. To do this, we consider theory alongside our experience as educators, to suggest a definition that accounts for the diverse contexts of our field. We start by considering existing literature on social justice within medical education and the importance of this conversation, before reflecting on how our experiences as global educators can help us to operationalise the principles of social justice. Simply, we suggest a definition of social justice focussed on the practice of medical education. We hope this operationalisation will facilitate action within medical education at individual and institutional levels.

Social justice is a powerful guiding principle for equitable social change. However, in medicine and medical education, its conceptualisation and application are less well-defined, possibly giving rise to the variety of our teams' reflections when we first discussed our understanding in relation to Robinson's poem. A comprehensive review of the literature pertaining to social justice within medical education is beyond the scope of this short article. As medical educators, we have chosen to focus our review on social justice within medicine, as we have the most intimate understanding of this profession. Our goal is to offer a conceptualisation with transferability for other professions.

Most prominently in medical practice and education, social justice work draws upon both Virchow's definition of social justice as equality of access to quality healthcare for all,¹ and Freire's critical pedagogy, which conceptualises social justice as an outcome of developing learners' critical consciousness.^{2, 3} More recently, Jain and Scott4 have highlighted a lack of attention to justice within educational design, in their work problematising individualistic approaches to institutional barrier removal. Research and commentaries on social justice within medical education highlight gaps in understanding, including how to operationalise the concept within teaching.² Despite a noted lack of understanding regarding the application of social justice to teaching, teaching publications are common, with both integrated^{5, 6} and elective⁷ approaches well-described. Most social justice curricula are founded on definitions aligned with the delivery of healthcare, rather than education.^{6, 7}

Despite plurality of definitions and noted gaps, there has been a recent flourishing of the acronym “JEDI” (Justice, Equity, Diversity, Inclusion) where, primarily within the United States, many initiatives have been renamed to encompass justice. Kuper et al.⁸ classify social justice as one of two ways in which justice is discussed within medical education (the other being justice as morality/law/ethics), though this classification is debated within wider philosophical literature. Though we encountered discussion around the importance of the shift to “JEDI” in addressing structural barriers,⁹ we felt the conceptualisation of justice, including social justice, in these discussions was often unclear, perhaps reflecting the diversity of conceptualisations we have outlined. Our concern is that, without a more nuanced focus on conceptualising social justice, little happens beyond renaming.¹⁰ The transformative power of social justice in driving contextually relevant solutions lies in a clear conceptualisation that empowers educators to utilise a common language to discuss a guiding framework for action in diverse contexts.

Evidently, multiple perspectives on social justice coexist, each offering important insights on practice. Whilst embracing plurality can enrich our thinking by providing interpretations that cater to different contexts and experiences, it also challenges us to integrate these varied perspectives into a cohesive educational approach that facilitates sharing of learning and action on inequality globally. To do this, we need to adopt an educational conceptualisation of social justice that incorporates theory and international practice. This will allow us to translate the more abstract ideas about social justice within key theory to the practice of medical education, enhancing our pursuit of equity. This is not “the” singular, comprehensive conceptualisation of social justice—rather, we propose “a” conceptualisation focussed on the practice of medical education, drawing on our experience as medical educators within the United Kingdom and Pakistan, prominent theory, and the contemporary needs of our field. This conceptualisation is likely to (rightly) shift, as our practice evolves, new challenges are identified, and others apply this conceptualisation to their own global context or profession. What we begin here is dialogue on a practice-focussed, diverse understanding of social justice, offering a springboard for future work in this area.

Dueñas et al.'s¹¹ clear and straightforward conceptualisation of social justice is rooted, suitably, in an exploration of the practical application of philosophy to health. This definition forms the basis of our conceptualisation, focussed on the practice of medical education. The definition draws on the philosophers Sen,¹² Gaita (who reminds us social justice should be grounded in deep respect for one another), and de Beauvoir (who advanced social justice by exploring gendered oppression) to define social justice as

We consider that this provides a broader view than definitions originating from Virchow—social justice encompasses not only access to quality healthcare but also access to societal resources and opportunities (as per de Beauvoir and Sen). It also expands beyond literature purely focussed on addressing barriers, advocating for environments that enable flourishing, thereby emphasising equitable outcomes (as per Gaita and Sen). Robinson's poem illustrated the daily stresses of hiding oneself. This suggests, in alignment with Dueñas et al.'s definition, that social justice concerns all elements of our social lives, and we need to take a broader focus than strictly health and barriers. Within medical education, this means implementing strategies and curricula that focus on understanding broader social factors influencing population well-being. This is already reflected in some educational scholarship describing social justice curricula—for example, Coria et al.'s⁵ curricula which addresses the social and economic consequences of poor access to care, in addition to health consequences, or Draper et al.'s⁶ longitudinally integrated curricula which, despite utilising a definition focussed on social justice in health, addresses structural and social factors. Despite application within curricula, we are yet to see this focus reflected in our field's definitions.

Although social accountability, advocacy, and social justice share a common goal in promoting equity, in our experience, they address different elements of the issue. Detailed work is needed to explore how these concepts connect theoretically. Here, we offer our perspective as educators on their practical interrelation within medical education.

Whilst accountability and advocacy are critical, social justice demands a more long-term view of creating an equitable social environment—it acknowledges that inequalities are embedded in systemic and historical injustices, such as racism, ableism, and socioeconomic disparities. Addressing these deep-rooted inequalities requires not only a focus on individual advocacy and accountability but also on systemic change and the redistribution of resources and opportunities. Social justice is complementary to accountability and advocacy in that it provides a broader framework within which we can understand and address social and healthcare inequality.

We might expand Dueñas et al.'s definition to capture this:

Medical education is trailing behind in the global pursuit of social justice. We have focussed on problematising, and individual action, at the expense of addressing structural inequalities. In exploring the intersection of theory and our practice as educators, we have suggested a definition of social justice that is focussed on change, and encourages consideration of social inequality and opportunity, in addition to health inequalities. In building on this definition, we can begin to meaningfully challenge deeply embedded systems of power and privilege that perpetuate disparities in health and wellness.

Just as Robinson speaks of the persistence needed to maintain a connection with his identity in an oppressive environment, we must move forwards with a renewed commitment to become socially just practitioners:

Megan Brown EL: Conceptualization; methodology; investigation; writing - original draft; writing - review and editing; formal analysis; resources. Komal Atta: Conceptualization; writing - review and editing; methodology; investigation; formal analysis; resources. Helen Church R: Resources; conceptualization; writing - review and editing; methodology; investigation; formal analysis. Riya George: Resources; formal analysis; investigation; methodology; conceptualization; writing - original draft; writing - review and editing.