Programs, policies, and technologies — particularly those concerned with health equity — are often designed with justice envisioned as the end goal. These policies or interventions, however, frequently fail to recognize how the beneficiaries have historically embodied the cumulative effects of marginalization, which undermines the effectiveness of the intended justice. These well-meaning attempts at justice are bounded by greater socio-historical constraints. Bounded justice suggests that it is impossible to attend to fairness, entitlement, and equity when the basic social and physical infrastructures underlying them have been eroded by racism and other historically entrenched isms. Using the case of Brazil’s National Health Policy for the Black Population, this paper proposes that bounded justice can contribute to justice discourses by serving as a concept, a proffering to a multi-disciplinary conceptual framework, and a potential analytic for those interested in the design of policy, technology, and programmatic interventions towards health equity.

The science of learning health systems (LHSs) has expanded to include equity aims. However, efforts toward this end are nascent. The purpose of this study was to critically examine how equity has been discussed in LHS literature. We conducted a critical scoping review informed by the bounded justice concept. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, Pubmed, Embase, Scopus, and CINAHL Complete (Ebsco) databases were searched to identify relevant literature from inception to June 2024. We used qualitative descriptive analysis for detailed extraction and to identify patterns across equity conceptions in the literature. The search strategy generated 420 articles. Forty articles met the selection criteria. Our analysis generated four interrelated themes: (1) equity as central, (2) equity as reducing risk, (3) equity as process, and (4) equity defined as population of interest. Most articles fell into the equity as central theme. Notably, 35 (87.5%) articles were published between 2020 and 2024. We also identified five emerging equity-centered LHS approaches. LHS equity science is emerging, though it still privileges narrow, Westernized approaches. It is imperative that future work more deeply engages health justice traditions to inform LHS theory, research, and practice.

V.Thambinathan, K.Lynch, M.Moya, et al., “Learning Health Systems, Equity, and Bounded Justice: A Critical Scoping Review,” Learning Health Systems10, no. 2 (2026): e70072, https://doi.org/10.1002/lrh2.70072.

Social equity provisions in cannabis legislation are premised on the hope that the profit generated around adult-use cannabis can be leveraged to ameliorate the damage done by racially biased enforcement of prohibition in black and brown communities. As such, they encapsulate an attempt to reconcile the history of racism in the enforcement of cannabis law through its new future as a profit generating commodity. These programs are gaining traction, but with minimal empirical examination. The development and implementation of these programs raises a number of questions in need of study that we outline in this paper. We argue that Creary’s concept of bounded justice-which critiques the inherent limitations of social justice projects that ignore structural forms of social exclusion-can provide a framework for critical understanding of the limitations of such programs, ethnographically grounded empirical research, and a framework for evaluating the justice impacts of legislation. Specifically, we argue that in order to interrogate the possibilities for social justice projects around cannabis, we must address equity at a deeper level by working with communities to investigate hyper-localized and historical factors that have influenced systems and structures.

Hendy K, Mauri AI, Creary M. “Bounded Equity: The Limits of Economic Models of Social Justice in Cannabis Legislation”. Contemp Drug Probl. 2023 Mar;50(1):121-135. doi: 10.1177/00914509221147133. Epub 2023 Jan 13. PMID: 37502491; PMCID: PMC10373104.

ELSI efforts long have been troubled by critiques that they privilege scientific frameworks and grant scientists the power to set ethical agendas. As the first director of the Human Genome Project’s (HGP) ELSI program, Eric Juengst, explained in reflections he wrote after leaving the role, the primary goal of the HGP’s ELSI program was to support, not critique, genomics. “The enterprise of genome research and the knowledge generated by it,” Juengst wrote, “were to be treated as ‘unalloyed prima facie goods’” (Juengst 1996, 68). ELSI’s aim was to create the policy tools that would ensure that these goods reached the public in the most efficacious manner. Rather than critically examining the role genomics played in reconstituting the natural and social order, the work of the ELSI program primarily focused on adapting existing ethical practices (e.g., informed consent) and legal instruments (e.g., patent law) to accommodate the new science. In short, to draw on and extend language that Melissa Creary (2021) powerfully provides, ELSI’s formation was bounded by the narrow goal of facilitating genomics, a form of science it believed to be inherently good.

Adsit-Morris C, NaDejda Collins R, Goering S, Karabin J, Lee SS, Reardon J. Unbounding ELSI: The Ongoing Work of Centering Equity and Justice. Am J Bioeth. 2023 Jul;23(7):103-105. doi: 10.1080/15265161.2023.2214055. PMID: 37339305; PMCID: PMC11034805.

In the era of precision medicine and expanding health information technologies, large representative datasets are considered necessary for addressing health inequities. Partially in response to groundbreaking research on racism and bias in information technologies (Buolamwini and Gebru Citation2018; Le Bui and Noble Citation2020), data-driven health equity efforts have come to emphasize inclusion in health datasets as a solution. Building on Ferryman’s (Citation2023) application of bounded justice to inclusion in precision medicine and biomedical research, we identify important ways that data-driven equity efforts that focus on inclusion and representativeness are deeply bounded and threaten to expose racially marginalized groups of people to unwanted surveillance and potential harm.

To that end, we focus on two illustrative examples: algorithmic fairness and expanding collection of social determinants of health (SDOH) data. We discuss how an exclusive focus on including racially minoritized patients in these data-driven equity efforts represents bounded justice because of (1) the dialectical of invisibility and hypervisibility (Ferryman Citation2023), (2) surveillance, and (3) racial realism.

Nong, P., & El-Azab, S. (2023). Hypervisibility, Surveillance, and Bounded Justice through Data-Driven Health Equity Efforts. The American Journal of Bioethics, 23(7), 115–117. https://doi.org/10.1080/15265161.2023.2207516

To date, attempts to address racially discriminatory clinical algorithms have largely focused on fairness and the development of models that “do no harm.” While the push for fairness is rooted in a desire to avoid or ameliorate health disparities, it generally neglects the role of racism in shaping health outcomes and does little to repair harm to patients. These limitations necessitate reconceptualizing how clinical algorithms should be designed and employed in pursuit of racial justice and health equity. A useful lens for this work is bounded justice, a concept and research analytic proposed by Melissa Creary to guide multidisciplinary health equity interventions. We describe how bounded justice offers a lens for (1) articulating the deep injustices embedded in the datasets, methodologies, and sociotechnical infrastructure underlying design and implementation of clinical algorithms and (2) envisioning how these algorithms can be redesigned to contribute to larger efforts that not only address current inequities, but to redress the historical mistreatment of communities of color by biomedical institutions. Thus, the aim of this article is two-fold. First, we apply the bounded justice analytic to fairness and clinical algorithms by describing structural constraints on health equity efforts such as medical device regulatory frameworks, race-based medicine, and racism in data. We then reimagine how clinical algorithms could function as a reparative technology to support justice and empower patients in the healthcare system.

El-Azab, Sarah, and Paige Nong. “Clinical algorithms, racism, and “fairness” in healthcare: A case of bounded justice.” Big Data & Society 10, no. 2 (2023): 20539517231213820.

I take up the call for a more nuanced engagement with race in bioethics by using Creary’s analytic of bounded justice and argue that it helps illuminate processes of racialization, or racial formation, specifically Blackness, as a dialectical processes of both invisibility and hyper-visibility. This dialectical view of race provides a lens through which the ethical, legal, and social implications (ELSI) of genetics and genomics field can reflect on fraught issues such as inclusion in genomic and biomedical research. Countering or interrupting racialization in precision medicine can involve asking how marginalized groups are made invisible or hyper-visible in various aspects of the research process. Incorporating these kinds of questions into biomedical research inclusion efforts could lead to potentially powerful engagements with marginalized groups and could provide the opportunity for stakeholders to engage with the ways that racialization can happen in real-time and might undermine good intentions.

Ferryman, Kadija. “Bounded justice, inclusion, and the hyper/invisibility of race in precision medicine.” The American Journal of Bioethics (2023): 1-7.