How Populism Affects Bioethics

This article aims at raising awareness about the intersection of populism and bioethics. It argues that illiberal forms of populism may have negative consequences on the evolution of bioethics as a discipline and on its practical objectives. It identifies at least seven potential negative effects: (1) The rise of populist leaders fosters “ epistemological populism, ” devaluing the expert and scientific perspectives on which bioethics is usually based, potentially steering policies away from evidence-based foundations. (2) The impact of “ moral populism ” is evident in legislative prioritization of the “ morality of common people, ” often solicited through popular consultations on issues like abortion, drug legalization, or LGBT issues. (3) Populist distrust in autonomous governmental agencies and advisory bodies, including national bioethics commissions, can compromise expert advice, challenging both their authority and decisions. (4) Populists may erode transparency by undermining institutions responsible for it, hindering access to vital information for bioethical research. (5) “ Medical populism ” creates adversarial dynamics, prompting politicians to make simplistic healthcare policy decisions based on political rather than informed criteria, adversely affecting vulnerable populations. (6) Radical-right populist parties ’ “ welfare chauvinism ” may shape healthcare policies, impacting service access and resource allocation, disproportionately affecting vulnerable groups such as migrants, but indirectly affecting the rest of the population. (7) Nationalist sentiments associated with populism may obstruct international collaborations, posing challenges for global bioethics that seeks to address ethical concerns beyond national borders. In summary, these dynamics raise significant bioethical concerns encompassing evidence-based decision-making, transparency, healthcare equity, and global collaboration. How bioethicists may respond to these challenges is discussed.


Introduction
The rise of populism on a global scale has undoubtedly cast its shadow across several aspects of society.Bioethics is not an exception.As a discipline, bioethics plays a pivotal role in addressing ethical challenges arising in life sciences, encompassing realms like medicine, public health, and the environment, among others.One of its practical objectives is to justify and sometimes change legislation or public policies to address problems in those areas.In this article, I argue that contemporary illiberal populism is exerting influence on the development and practical objectives of bioethics, potentially hindering its fundamental goals.
One of the key strengths of bioethics lies in its commitment to values such as justice, health equity, and open public deliberation, among others.However, the intrusion of populism, which often thrives on divisive rhetoric and simplistic solutions, may introduce obstacles in the realization of these values.Populist movements have been known to challenge established legal norms and institutions, sometimes questioning the scientific consensus and dismissing expert opinions.This anti-establishment stance can create an environment where evidence-based bioethical considerations may face resistance or be overlooked.
Moreover, the populist surge may impact the very foundations of bioethical analyses and the development of legislation and public policies.The emphasis on ethically criticizing, justifying legislation, and formulating public policies could be swayed by populist ideologies that prioritize immediate public sentiment over carefully considered ethical principles.This shift may jeopardize the pursuit of justice and equity in healthcare, as decisions might be influenced more by populist narratives than by a comprehensive ethical framework and the search for consensus.The potential consequences are farreaching.Populism's impact on public discourse and policymaking may impede the objective evaluation of bioethical issues, hindering the advancement of solutions rooted in ethical considerations.
This article aims to raise awareness about the intersection of populism and bioethics.As populism continues to shape political landscapes, its effects on those areas covered by bioethics merit close examination.By fostering a better understanding of these dynamics, we can work towards safeguarding the integrity and objectives of bioethics in an era marked by the challenges posed by illiberal populism.
This article argues that populism may affect both the development of bioethics as a discipline and its practical objectives in at least the following ways: (1) Populist leaders exhibit anti-expert and anti-science attitudes, leading to a devaluation of expert opinions and ethical guidelines in bioethics.This inclination towards "epistemological populism" may result in less evidence-based policies driven by populist narratives.(2) The influence of "moral populism" is evident in the prioritization of "the morality of common people" in legislation and policy-making, often facilitated through popular consultations and referendums, particularly on issues like abortion, drug legalization, or LGBT issues.(3) Populists distrust governmental autonomous agencies and advisory bodies, such as national bioethics commissions, which provide expert advice that may conflict with populist policy or legislative preferences, or may even challenge the authority and decisions of populist leaders.(4) Populists erode transparency by weakening institutions responsible for it, hindering access to essential information for bioethical research.( 5) "Medical populism" creates adversarial dynamics among "the people" whose lives have been put at risk by "the establishment" (the government, Big Pharma, medical experts, etc.).This framework leads politicians to take usually simplistic policy-making decisions based on political and not informed healthcare criteria, which may have a negative effect on vulnerable populations.(6) Populist movements' nationalism may shape healthcare policies in what has been called "welfare chauvinism," impacting access to services and resource allocation, potentially affecting vulnerable migrant populations.Finally, (7) the nationalism usually promoted by populism may limit international collaborations, posing challenges for global bioethics, which aims to address ethical concerns beyond national borders.Overall, these factors raise significant bioethical concerns related to evidence-based decision-making, ethical principles, transparency, healthcare equity, and global collaboration.
It is important to note that the impact of populism on bioethics can be context-dependent, and not all populist movements may have the same effects.Since there are right-and left-wing populisms, the kind of attitudes they may have on bioethical issues varies significantly.I construct my argumentation around the case of Mexico, where in 2018 a politician usually recognized as a populist, Andrés Manuel López Obrador, became president.However, since no single case may represent all the threats that populism represents to bioethics, I also base my analysis on the cases of the United States, Brazil, and Italy, among others, where populism has had an impact on situations of bioethical concern.

What is populism?
Although there are different definitions of populism, one that is widely accepted by a number of authors in the area of populism studies is the ideational definition presented by Cas Mudde and Cristóbal Rovira-Kaltwasser, according to which populism is a "thin-centered ideology that considers society to be ultimately separated into two homogenous and antagonistic groups, 'the pure people' versus 'the corrupt elite' and that politics should be an expression of the volonté général (general will) of the people" (italics in the original). 1It is "thin-centered" meaning that it is an ideology limited in ambition and scope, which allows it to be combined with different ideological traditions; there are no ideologically driven public policies that populists are necessarily going to support.Populism is compatible with right-as much as with left-wing politics.
The two groups in which populists divide society are antagonistic because "the pure people" is conceived as good and wise, while "the corrupt elite" is immoral and has been taking advantage of "the people."It is basically a moral distinction, and, by definition, populist movements and leaders are going to be anti-elite and are going to represent and defend the interests of "the people."These two groups are conceived as homogeneous: neither the people nor the elite are taken as groups within which a plurality of different moral and political views coexists.In particular, populism tends to have an anti-pluralist, selective, and exclusionary view of "the people."As Mudde says: "The main bad is that populism is a monist and moralist ideology, which denies the existence of divisions of interests and opinions within 'the people' and rejects the legitimacy of political opponents." 2 The populist's image of "the people" is at odds with the idea that complex societies are constituted by a plurality of points of view, identities, and interests.Populists put aside these differences and insist on the unity of the people in their struggle against the elites.That is why populists are not only anti-elitists but also anti-pluralists, since they claim to exclusively embody "the authentic people" against "the enemies of the people." 3 They also insist that the mandate of the people is clear and absolute, which "can legitimize authoritarianism and illiberal attacks on anyone who (allegedly) threatens the homogeneity of the people." 4 Although there have been various forms of populism throughout history, contemporary populism tends to take illiberal, authoritarian, and generally exclusionary forms, 5 because they do not grant moral authority to those with perspectives different from their own (anyone who differs from their opinion represents "special interests," i.e., represents the elite), and they tend to set aside democratic mechanisms that would allow those perspectives to prevail in political or legislative debate.

Anti-science and against the expert elite
The harmful effects of populism on bioethics have to be seen, first and foremost, against the background of populism's negative attitude towards science, scientists, and experts in general.Scientific experts are identified as part of the elites populists oppose.When populist leaders talk about "the elite," they usually refer not only to the political establishment, to the "traditional politicians," mainstream political parties, the media, the upper classes, but also to the cultural and scientific elite. 6Intellectuals and scientists are usually identified as part of the corrupt elite: the scientific elite has been co-opted by the economic and political elites.In the narrative of some left-wing populists leaders, for instance, this scientific elite has been at the service of the neoliberal order that has prevailed in recent times, and which they oppose, since they identify it as the cause of the huge inequalities that prevail nowadays in many countries-and which many specialists also identify as one of the sources of the revival of populist leaders and movements.For instance, in Mexico, López Obrador has repeatedly accused scientists of being part of "those who have perpetuated corruption" in the country, as an "academic oligarchy" that only wants to maintain their privileges. 7 , 8The animosity towards scientists in Mexico has even reached extremes: in 2021, his administration promoted the judicial prosecution of 31 distinguished scientists and directors of scientific institutions from previous administrations on charges of corruption. 9The government intended to imprison them, although some were later acquitted. 10ttacking scientists can be a way for populist leaders to appeal to their base by framing experts as disconnected from the concerns of everyday people, and not being at the service of "the people."By attacking scientists, populist leaders create a narrative that positions themselves as champions of the people against an out-of-touch establishment.This tactic plays into the broader populist rhetoric of portraying experts as serving their own interests and privileges rather than the needs of the everyday citizen.Populist leaders often use anti-intellectualism and skepticism of expertise to bolster their political appeal, even if it means undermining the credibility of scientific institutions.This approach can have consequences for public trust in scientific evidence and may lead to policy decisions that prioritize shortterm gains over evidence-based, long-term solutions.
Populist leaders may at times attack scientists whenever scientific findings challenge populist policy positions or contradict populist narratives.Populism is often seen as a variety of so-called post-truth politics.Oxford Dictionaries define "post-truth" as "relating to or denoting circumstances in which objective facts are less influential in shaping public opinion than appeals to emotions and personal beliefs."Populist leaders appeal more to emotions and tend to subordinate facts to their political point of view, which often goes against scientific truths.In post-truth politics, the debate is no longer based on objective facts and evidence-verified data, but on assertions devoid of factual evidence that are repeatedly affirmed as if they were true and that usually respond to political affiliations.Populist movements and politicians often use social media as a mouthpiece for "fake news" and "alternative facts" with the intention of inciting negative emotions against their opponents.
By undermining the authority of science, populism also questions the authority of bioethics based on that same science.The lack of trust in experts and in science and their anti-intellectualism makes it more difficult for any bioethical recommendation based on scientific data to achieve consensus or be seriously considered by decision-makers.Furthermore, populist politicians usually have a simplifying discourse that erases the complexity bioethical issues generally have.The populist style devalues complexity and substitutes it with a rhetoric of simplicity, directness, and alleged common-sense, which often go hand in hand with anti-intellectualism-something that Paul Saurette and Shane Gunster have called "epistemological populism." 11Epistemological populism relies on populist rhetorical strategies to exalt the knowledge of ordinary people, emphasizing their proximity to everyday life.It contrasts this with the perceived detachment of elites from common experiences.This epistemological populism asserts the superiority of individual opinions rooted in firsthand experience over theoretical or academic knowledge.It prioritizes specific experiences as reliable sources, extends this authority to unrelated issues, favors emotional intensity as a marker of opinion reliability, dismisses alternative knowledge as elitist, and often concludes discussions with an appeal to "common sense." Epistemological populism undermines the authority of scientists and of science itself, which the government sees as an ideological or politicized science-in the case of Mexico, the López Obrador administration has even referred to it as "neoliberal science," 12 opposed to a "popular science," which, among other things, seeks to rescue the traditional knowledge of indigenous people and aims at being at the service of the people.
This skepticism towards science has consequences.During the COVID-19 pandemic, in many countries with populist governments, the information on which the fight against the health emergency was based was not supported on scientific evidence but rather subject to data motivated by political or economic interests.Several populist governments disqualified public health measures based on scientific evidence, such as the use of masks.Populist leaders such as Jair Bolsonaro, Boris Johnson, Donald Trump, or López Obrador refused to take the opinion of experts and to wear masks or recommend them to the population, promoting skepticism about their effectiveness.In Mexico, Undersecretary of Health Hugo López-Gatell, the country's COVID-19 czar, dismissed the use of mask, saying that it was "unnecessary as a protection mechanism that does not have strong scientific evidence." 13The scientific consensus, on the other hand, was that the mask was one of the most effective mechanisms to prevent contagion.Likewise, Mexican authorities repeatedly suggested that asymptomatic carriers could not infect others and that it was not necessary to carry out tests because doing so "had no scientific basis," 14 but scientific evidence showed otherwise: that asymptomatic people were the ones spreading the disease the most.The Trump administration also sought to stop testing asymptomatic carriers in an effort to lower the numbers of people infected with COVID-19, 15 which had a clear political motivation behind it.
Another consequence that these attacks on scientists and science have had in countries with populist leaders and parties is a decrease of funding of certain areas of scientific and bioethical research.López Obrador cut the budget of some research centers up to 75%. 16During his first year in office, Trump proposed for "massive cuts" to spending on medical and scientific research, public health and disease prevention programs, and health insurance for low-income Americans and their children.Cuts to specific programs in the budget included: $333 million to CDC programs to fight infectious diseases; $136 million to CDC Office of Public Health Preparedness and Response; $76.3 million to CDC Center for Global Health; $3.7 billion to NIH funding for researchers; elimination of the Fogarty International Center, which trains scientists, clinicians and bioethicists to work in developing countries, among others. 17oral populism" Given their moralistic conception of politics, a good part of the crusade of populists is moral, but they tend to understand morality as that which emanates from the traditions and customs of the people and not necessarily the one arising from the public deliberation in which bioethical theories may take partwhich may even interfere with the moral projects that populists support.Therefore, from their point of view, it is important to rescue and promote traditional morality against the corruption of the elite, whether through "moral constitutions," national codes of ethics, or some document that rescues the values and principles of the morality of the people.With these types of actions, a message is sent that, unlike their predecessors, they do care about morality.For instance, in 1999, Hugo Chávez in Venezuela tried to add to the Constitution a fourth power (in addition to the executive, legislative, and judicial powers), the "Moral Power," in charge of "the prevention and punishment of those acts considered as attacks against public ethics and administrative morality."It would also be in charge of training Venezuelans "in the exercise of civic virtues, the promotion of citizen education, the development of solidarity and the exercise of freedom and democracy." 18owever, this is a fundamentally conservative project that perpetuates the established and predominant morality in the country.This morality, oftentimes based on traditional and religious perspectives, is not infrequently found in tension with some of the values and principles of bioethical theories, many of which are based on a secular vision and on human rights.
In the populist perspective, it is not experts in bioethics the ones who should contribute to solve controversial moral issues participating in processes of public deliberation, along with scientists and other members of society: these issues should be subjected to direct popular consultations or referendums.There is a predilection of populist leaders for direct democracy as a form of manifestation of the popular will.Populists usually propose that controversial issues such as abortion, same-sex marriage, trans rights, or the legalization of drugs be solved on the basis of consultations in which that popular will is manifested.For example, before becoming president, López Obrador invariably evaded the issue of abortion at public events and never publicly committed to its decriminalization.Already as president, he said that the issue of decriminalizing abortion should be subject to consultation, but that "it is a debate that we should not open." 19Thus, his way of evading a clear response to the issue was to affirm that it should be subject to consultation."When we have to decide on a controversial issue we say: let's go to consultation, to democracy, to not impose anything.'Nothing by force, everything by reason and law.'" 20n a similar fashion, right-wing populist Javier Milei, president of Argentina and who has declared himself pro-life, has proposed a referendum on the issue, opening the possibility of "eliminating the law" that legalized abortion if the citizens so decided. 21Putting the decriminalization of abortion up for popular consultation would most likely endorse the criminalization, given that the majority of Mexican and Argentinean populations are conservative on social issues.
Consultations of this kind have other negative consequences: the first one is that they honor the views of the majority and overlook the moral perspectives of minorities.Another one is that complex issues are simplified and nuances are lost, responses are limited to polarized options, which deepens the confrontation, contributes to a misunderstanding of the contrary position and to its caricature, and makes argued dialogue and agreements harder to reach.Additionally, consultations or referendums are also misleading because they tend to mask authoritarian policies under the democratic cloak of citizen participation.As Jan Werner-Müller says, "A referendum isn't meant to start an open-ended process of deliberation among actual citizens to generate a range of well-considered popular judgments; rather, the referendum serves to ratify what the populist leader has already discerned to be the genuine popular interest as a matter of identity, not as a matter of aggregating empirically verifiable interests." 22here are also some other negative consequences: as human rights advocates have repeatedly responded to these proposals, fundamental rights cannot be subjected to consultations.Access to a legal and safe abortion has to do with the rights to healthcare, to decide on one's own reproduction, and to privacy among the most important ones, which cannot be subjected to consultations.But the defense of women's rights is not only often secondary to populist politicians, it is sometimes an obstacle to their political projects.This is because feminism and populism are two movements that in various ways go in opposite directions: while feminism is an emancipatory movement, populism oftentimes tends to be exclusionary and in many ways socially conservative and traditionalist. 23It tends to privilege the expression of the voice of the people, often conservative, over the feminist agenda on issues such as abortion or assisted reproduction techniques.This has also been the case with LGBT rights, which are also part of an emancipatory movement.In populist governments-especially right-wing ones-the probability increases that the preferences of a majority prevail over the rights of a minority, especially if that minority is not viewed positively by society.If the recognition of these rights in conservative societies goes through direct democratic mechanisms, such as referendums, there is a higher probability that they shall not be recognized. 24 , 25any issues concerning bioethics, from the populist perspective, should also be determined by religion, which is seen as another manifestation of the popular spirit.Thus, it is not surprising that several Latin American populist leaders such as Nayib Bukele, Bolsonaro, or López Obrador, instead of adopting public policies based on scientific evidence, adopted religious elements in their speech and recommended, for example, praying or entrusting oneself to some religious figure in the face of the COVID-19 pandemic-all this, in many cases, in violation of the secular character of the State that prevails in some of those countries. 26The secular State is a guarantee for the coexistence of a plurality of moral perspectives, and in that sense it is also a guarantee for bioethics.

Bioethics advisory bodies
An area of practical application of bioethics has been the setting up of national bioethics advisory bodies, some of them sponsored by the government, such as national bioethics commissions.These bodies are usually comprised of experts in different areas and advise on government policies and legislation on issues of bioethical concern.However, they find resistance from populist leaders because they distrust this kind of autonomous agencies or advisory bodies.This happens for several reasons.Autonomous advisory bodies, by definition, operate independently, but that means that sometimes they provide expert advice that may conflict with populist policy or legislative preferences, or may even challenge the authority and decisions of populist leaders, who, driven by a desire for immediate and visible results, may resist or reject recommendations that challenge their preferred course of action.They also often prefer centralized power and may view these advisory bodies as undermining their control.Autonomous agencies and advisory bodies, especially if staffed by experts or perceived as elitist, can be seen as part of the establishment that populists criticize-attacking them reinforces the populist narrative of being an outsider fighting against the entrenched interests of the elite.Populist leaders may argue that these independent bodies are not democratically elected and, therefore, lack accountability to the people.They might prefer institutions directly under their control, which they perceive as being more responsive to the "will of the people."Independent agencies and advisory bodies can act as checks on misinformation, which populist leaders may view as a threat to their ability to shape public opinion.
It is not surprising that public advisory bodies that may have a different moral perspective are uncomfortable for populist leaders and that they try to diminish their power and autonomy.The case of Mexico is once again illustrative.At the beginning of the COVID-19 pandemic, on April 2020, the president of the National Bioethics Commission (Conbioética) resigned from his position. 27Afraid of the possible autonomy of Conbioética, the administration left it without a president until February 2022, that is, for almost two years, which coincided with the worst period of the pandemic.Conbioética should have been in charge of not only advising on government policies but also of supervising the research ethics committees that intervened in the development of vaccines in which Mexico participated, but this commission abdicated its responsibility during that time.Conbioética seemed to hinder the government in making decisions on ethical issues, for which the government had positions that should not be consulted.The government decided which research ethics committees would supervise the trials and provided its own narrative of the response to the pandemic.The government just did not want to risk the chance of having an autonomous advisory body that would not align with its narrative, support its policies, or pose challenges to its authority.
What happened in Mexico has happened in other countries with populist governments.Since 1974with the exception of George H. W. Bush's administration-all the presidents of the United States have created some type of national bioethics commission or a president's commission. 28The aim of these commissions was to identify and advocate for policies and practices that guarantee the ethics of scientific research, healthcare delivery, and technological innovation.Democrats and Republicans alike have seen the need for such commissions, although they have sometimes put bioethics to political use to justify certain types of liberal or conservative policies, as the case may be.However, Trump broke that tradition by refusing to create a bioethics commission.Despite the fact that for four years the country went through events with bioethical implications, including a one-in-a-century pandemic, Trump did not convene any type of experts in bioethics, making alone the decisions related to the fight against the pandemic.Trump also disdained the opinion of experts such as Anthony Fauci, which has been seen as part of that administration's disdain for science-a disdain that was also manifest in his environmental and energy policies. 29(Oddly enough, Joe Biden has not appointed a bioethics commission either, even though bioethicists have publicly asked him to appoint one. 30)

Undermining transparency and access to information
Over the last 50 years several countries have enacted legislation aimed at protecting the right to freedom of information, as well as promoting a more transparent and accountable state.Information disclosure may help in addressing and solving not only political and social issues but also bioethical ones.Public policies on issues such as public health or the environment must be based on the openness of information and the verification of the facts that are cited as evidence.They must also be based on good bioethics, which requires reliable and verifiable data as well.Governments and autonomous public agencies are responsible for generating much of this information.If the information they generate is not reliable or cannot be subject to verification by other agents, if it cannot be available because it is hidden for political purposes, then that will affect the information collected by bioethics, as well as the legislation or public policy justified therein.
However, populist leaders tend to limit access to information and weaken the institutions in charge of transparency, which are crucial for bioethics.Again, they seek to undermine the autonomy of public agencies that specialize in the protection of fundamental rights, such as freedom of information.In Russia, Vladimir Putin has expanded state secrecy; in Hungary, Victor Orbán's Fidesz party seeks to establish what he has called an "illiberal state" that limits access to information; in Brazil, Bolsonaro reduced government transparency and led attacks on independent journalists. 31nce again, the case of Mexico is illustrative: López Obrador has led an attack against the National Institute for Transparency, Access to Information and Personal Data Protection (INAI for its acronym in Spanish), arguing that it is too expensive, only represents the interests of the elite, and that it was complicit in the abuses and corruption during the "neoliberal period." 32Since March 2023 and for several months, INAI's work was paralyzed because López Obrador stopped the process of appointing two members of the institute's board of directors, which meant that it could no longer continue working, leaving thousands of requests for information pending resolution.In 2021, INAI received more than 296,000 requests for information, many of them related to public healthcare issues, health risks, clinical trials ran with public funds, vaccination, public spending on medicines, population, and the environment, among others. 33Much of this information is crucial for bioethical research.
Not surprisingly, the number of cases of non-compliance of transparency requests tends to increase in populist governments.During the first four years of López Obrador's administration, the number of complaints due to lack of transparency increased by 19% compared to the same period of the previous government. 34The Trump administration denied a greater number of information requests and had more freedom of information lawsuits than previous administrations.Bolsonaro's compliance was also below that of his predecessor, Dilma Rousseff. 35ikewise, populist politicians tend to weaken transparency through regulatory measures.López Obrador categorized much of the information related to the pandemic as "classified" or as "national security," 36 so that, for example, there is no access to information on the number of participants in the clinical trials being carried out in Mexico, the conditions under which they were carried out, nor about which research ethics committees supervised these trials.
Populist politicians also use legal tactics arising from executive prerogatives to erase information that may have political uses contrary to their interests.For example, the Trump administration tried to boycott the 2020 census by allocating the same amount of public funds to carry out the population census as the Obama administration had in 2012, despite the fact that the population had grown by 20 million and that, therefore, the census would need more resources than the previous one.It also shortened the period in which the census would be carried out.This also led to the underestimation of racial and ethnic minorities. 37This has consequences not only for political representation but also for the type of health policies that will be implemented in the different communities. 38Similar ways of boycotting censuses have happened in Brazil, where in 2021 Bolsonaro reduced the budget of the Brazilian Institute for Statistics and Geography by 96%, in charge of carrying out the census. 39In India, Narendra Modi, another politician usually taken to be a populist, indefinitely postponed the census that would have been carried out in 2021 due to the COVID-19 pandemic. 40The consequences of information gaps in a census, or the lack of it, are profound, not only for economic and public policy purposes.For instance, undercounting hard-to-reach populations creates a fictional image of a country, which will do little to improve the needs of the people.The way the data is collected, as well as the quality of this data, has an impact on fields related to bioethics: on the allocation of healthcare resources, just to mention one.One can hardly determine a fair allocation of resources without accurate information about the population's needs.Census counts, for instance, affect the number of vaccine doses allocated to each community.
Finally, populist leaders often target independent journalism, usually portraying them as part of the corrupt elite and labelling them as "fake news" or as "enemies of the people."Populist's anti-pluralism and their conception of the people as homogeneous put them in direct confrontation with critical journalism: they demand journalists to represent the uniform perspective attributed to "the people," and they take any criticism to their leadership as an attempt to undermine the people's will, when not as an elitist conspiracy to subvert "the will of the people."These attacks not only contribute to a divisive polarization but also diminish the public's trust in the news media, potentially hindering its ability to serve as a watchdog and alternative source of information when official channels are compromised, therefore compromising journalism's ability to fulfil their role within democracy. 41This raises significant challenges for the field of bioethics, as a lack of plurality of media outlets and a lack of transparent and objective information may obstruct the development of evidence-based research and public policies in areas such as healthcare or the environment.
Influence on healthcare access Gideon Lasco and Nicole Curato introduced the concept of "medical populism" to refer to a politicized response to medical emergencies.According to them, it is "a political style that constructs antagonistic relations between 'the people' whose lives have been put at risk by 'the establishment,'" 42 where "the establishment" can refer to the government, Big Pharma, medical experts, or even "the West."On the other hand, medical populism portrays "the people" as victims of negligence, whose health and safety are under threat.Additionally, it dramatizes health crises, providing a rationale for unconventional responses and urgent actions, which in many cases bypass the complex nature of policy-making that often requires consultation with medical experts and bioethicists.Finally, medical populism advocates and validates simplistic and spectacular solutions to health emergencies.
This kind of medical populism may shape healthcare policies, including access to health services and the allocation of resources.Depending on the nature of the populist agenda, this could affect the distribution of healthcare resources and disproportionately impact vulnerable populations, including those with limited access to healthcare.Bioethical concerns related to social justice, healthcare equity, and the fair distribution of medical resources may also be affected.
Once again, populist leaders may undermine or dismiss the advice of health experts and bioethicists in favor of policies that align with their political agenda.This can lead to decisions that are not grounded in scientific evidence, sound ethical considerations, or best practices, potentially compromising the effectiveness of health resource allocation.
In Mexico, the López Obrador administration decided, very early in his administration, to stop buying from big pharmaceutical companies and distributors that had traditionally supplied medicines to the public healthcare sector, claiming that Mexico would not be "hostage to Big Pharma," and without providing any evidence also accused them of corruption.Moreover, as part of a government austerity policy, arguing that the pharmaceutical distributors were mere intermediaries, the experts in drug distribution from private companies were replaced by politicians loyal to the government, but with no expertise on the subject.The money saved would be used for the government's social programs.All of this caused a shortage of medicines throughout the public health sector, affecting the most vulnerable populations that depended more on specialized medicines, such as psychiatric and cancer medicines.Millions of medical prescriptions were not filled.Particularly dramatic were the consequences for children with cancer, who stopped receiving their medications.According to some patient rights organizations, by 2021 this shortage had affected some 19,000 children throughout the country, and some 1,600 had already died. 43As patients' rights advocates and family members complained, a government official accused them of being part of a campaign of international right-wing groups. 44 , 45edical populism led the government to fail to fulfil its moral duty of healthcare provision.As Napoleon Mabaquiao Jr. and Mark Anthony Dacela state, "When a government's adoption of medical populism leads it to mishandle the relevant constraints to its moral duty of healthcare provision, then it, in effect, violates its people's moral right to healthcare." 46 As part of the spectacular and unconventional solutions to health emergencies that characterize medical populism, in December 2023, the government created a "Mega Pharmacy," a facility López Obrador described as "possibly the largest pharmacy in the world."This centralized pharmacy is intended to fulfil prescriptions from all over the country.However, critics question "whether the government will have the capacity to purchase and distribute thousands of medications on a national scale from one central location." 47The government has shown not to have it in the past.
In other countries, populist anti-science attitudes have also had an impact on some crucial healthcare programs, most notably those related to vaccination.This is not a coincidence.Populist movements often thrive on a general distrust of the government, international organizations, and experts, particularly among disenfranchised populations.In the case of medical populism, as mentioned, this distrust includes Big Pharma, public health organizations, medical experts, and bioethicists.Anti-vaccination sentiments and vaccine hesitancy seem also to be fueled by a mistrust of the same institutions, leading people to question the safety and efficacy of vaccines.Anti-vaccination movements similarly reject the consensus within the scientific community regarding the safety and importance of vaccines, relying on anecdotal evidence, misinformation, and conspiracy theories instead-they tend to exploit the alleged link between vaccines and autism, based on the bogus research by Andrew Wakefield in 1998, even though it has been amply discredited.
Populist movements and politicians often rely on emotional appeals and the construction of a collective identity.Anti-vaccination movements may take advantage of these emotional aspects, framing vaccine decisions as matters of personal choice, freedom, and identity.The rejection of vaccines can become a symbol of resistance against perceived external control-something that goes well with the individualistic and libertarian tendencies of some right-wing populists.
Populist leaders may also play a role in shaping public opinion on vaccination.If a populist leader expresses anti-vaccination views or questions the legitimacy of vaccination programs, followers may be more likely to adopt similar beliefs.This is the case of Italy, which in 2018 had the second largest measles outbreak in Europe, with more than 4,000 cases and four deaths, following two years when vaccination rates fell below 90%.This happened as the populist Five Star Movement and the far-right League backed anti-vaxers' conspiracy theories, even proposing legislation against vaccines. 48In an analysis of the relation between populism and vaccine hesitancy in Europe, Jonathan Kennedy shows a highly significant positive association "between the percentage of people in a country who voted for populist parties and who believe that vaccines are not important." 49Other studies conducted across Europe show similar conclusions: "Those countries in which their citizens present higher populist attitudes are those that also have higher vaccine-hesitancy rates." 50tionalism, migration, and "welfare chauvinism" Populism and nationalism are different phenomena and, as such, should be conceptually distinguished, although they are usually closely related.Populism is structured around the antagonism between "the people" and "the elite," whereas nationalism is structured around the concept of "the nation," conceived "as a limited and sovereign community that exists through time and is tied to a certain space, and that is constructed through an in/out (member/non-member) opposition." 51However, populist movements and leaders have articulated populism and nationalism-particularly right-wing populists have combined exclusionary forms of ethnic-cultural nationalism, or nativism, and xenophobia, ultimately holding that states should be inhabited by members of the native group ("the nation"), while nonnatives or foreigners ("outsiders") threaten the homogeneity of the nation-state.
Populist movements and leaders, especially populist radical right (PRR) parties, usually embrace an exclusionary form of nationalism, according to which the political elite has furthered the rights of immigrants, against the interests of the people (understanding "people" as "nation"), affecting healthcare services for the country's people.As a reaction, there has been a tendency among these parties to call for limiting or denying healthcare benefits for migrants ("out-groups") while providing them for the native people of the country (a hypothetical "in-group").This has been called "welfare chauvinism" or "welfare populism" and constitutes a form of nativism. 52n a scoping review of academic literature on how PRR parties have influenced welfare policies, Chiara Rinaldi and Marleen Bekker 53 show the negative implications this has had on the population's health of several European countries.According to the literature reviewed, countries such as Austria, Denmark, Poland, Italy, the United Kingdom, the Netherlands, among others, where PRR parties have entered government, welfare chauvinism has materialized into policies that exclude migrants from welfare benefits or indirectly target them through measures affecting the entire population, such as restrictions on the eligibility for unemployment benefits and public medical services.Paradoxically, while trying to protect their "own people" from "undeserving" groups, PRR parties may end up affecting the healthcare of the population they were supposed to defend.

Distrust of supranational organizations
Nationalistic populist movements and politicians may often be less inclined to engage in international collaborations, since they tend to distrust supranational organizations that are above and beyond the power of the people.This can have implications for global bioethics, which often involves addressing ethical issues that transcend national boundaries.Populist leaders distrust supranational or multilateral organizations that may limit the sovereignty and autonomy of the nation and call to resist this shift of political power to these organizations and reclaim that power goes back to the country's people-as Brexit case, and more generally populist "Euro-scepticism," illustrates.Supranational organizations, by design, involve collaboration and joint decision-making, which may be seen by populists as compromising the sovereignty of the nation. 54The sovereignty of a national state comes from that nation's people; therefore, constraints from supranational organizations are seen as undemocratic, not only because their power does not derive from the consent of those affected by their decisions but also because they do not seem to be accountable to the people.This attitude has been called "populist sovereignism," that is, the idea that "no external force, group, or institution should be able to circumscribe the authority of the state, in part because doing so would also circumscribe the 'will of the people' within the state." 55In this individualistic conception of autonomy that bioethics has traditionally adopted.Bioethics should address this issue more seriously than it has done in the past, for instance, by exposing the ways in which individual autonomy relies on interdependence.This may help counteract the conflict and resentment that populists exploit.
They also recommended that bioethics puts more emphasis on justice.Some of the conditions that have given rise to populism have to do with the economic inequalities that have been accentuated in the past few decades, particularly with the crisis of the welfare State and the implementation of neoliberal economic policies.Many political elites have been indifferent to this phenomenon; healthcare policymakers have not done much better."Bioethics needs to move beyond its traditional conversations about liberty and equality to produce scholarship and policy analysis that jump-starts new discussions about the problem of injustice," they claim. 60In this sense, bioethics should put more attention on the social determinants of health, that is, the non-medical conditions that influence health outcomes, such as those in which people are born, grow, work, etc., but that also include the economic and social policies and the political systems that affect those conditions.
Bioethics must actively engage in democratic participation and civic education, extending beyond political processes to cultivate well-informed citizens.This entails developing skills to collaboratively address shared challenges like social injustice, abortion, euthanasia, and climate change.Populism's impact on bioethics, evident in information reliability concerns, underscores the need for bioethicists to identify trustworthy evidence.They should then translate this evidence into accessible language, conveying the complexity of moral issues without oversimplification.Concrete actions, such as vaccination and sustainable energy adoption, should result from these efforts.Collaboration with opinion leaders, utilization of technological platforms, and media engagement are crucial for disseminating bioethical recommendations effectively.It might be claimed that bioethicists already do most of these things.We should keep doing them, but now with the additional goal of facing the risks posed by populism.
Above all, bioethicists should denounce the populists' tendency to see academics, and bioethicists in particular, as an "expert elite" that takes decisions without taking into account the perspectives of "the people."Bioethicists have invested a good amount of effort debating about the appropriate role of public opinion, expertise, and deliberative democracy processes in shaping public policies. 61 , 62The division of society into these two homogeneous and antagonistic blocks is debatable.It may not be the task of bioethics to analyze and question populism's conceptual framework, but it may help in stressing the plurality of moral perspectives that coexist within society, particularly within these two supposedly homogeneous and antagonistic blocks.Bioethicists usually make their recommendations based on public debates in which a plurality of voices takes part.The field is far from being monolithic, and disagreement is one of its hallmarks.
Bioethicists should take distance from the idea of being part of an elite as opposed to the people.It may be true that some health professionals, clinical researchers, and various academics have been co-opted by authoritarian regimes and corporate interests in the past, and that their actions have not always been up to ethical standards.It is the labor of bioethicists to pay close attention to these cases and denounce them, especially since they themselves may be subject to the same political and economic pressures.It is up to us to point out the ways in which the moral obligations of healthcare professionals and other areas related to bioethics may conflict in clinical trials, public policies, or laws that are subject to their consideration.
Finally, bioethics is in a privileged position to defend the hard-won liberties that seem to be threatened with the rise of authoritarian and illiberal forms of populism.Academic freedom, freedom of information rights, minorities' rights, and others seem more vulnerable now than what we previously thought.So are some of the autonomous public agencies and institutions in charge of their protection, human rights organizations, and even some of the international organizations that had been so hard to build.Bioethics relies on many of these rights, as well as on the work of these organizations; bioethics should take part in their defense more than ever before.