Ethical and relational injustice in health care for people experiencing homelessness

Abstract

Ethical considerations: Equitable access to healthcare is a fundamental right recognized internationally. However, people without stable housing face multiple structural, administrative and relational barriers that limit this right, especially in European contexts such as Spain. Women experiencing homelessness also suffer specific forms of discrimination and violence that exacerbate their vulnerability.

Objective

To explore the experiences of people affected by homelessness in their interaction with health services in Spain, identifying barriers, experiences, and proposals for improvement from an ethical, gender, and comparative European perspective.

Methodology

Qualitative phenomenological study based on semi-structured interviews with five homeless adults and a professional in the social and health care field. The selection was made by convenience sampling in a municipal homeless shelter. The thematic analysis followed Giorgi’s approach, with triangulation, independent coding, and feedback of preliminary results. Informed consent, anonymity, and compliance with the ethical principles established by the Declaration of Helsinki were guaranteed.

Results

Four central dimensions were identified structural and organizational barriers, such as lack of documentation or means of contact experiences of treatment, marked by stigma and unequal recognition coping strategies and proposals for improvement; and a European perspective, which highlights effective models such as Housing First. The gender dimension revealed specific needs in sexual and reproductive health and protection from violence.

Conclusions

Healthcare for people experiencing homelessness requires an ethical approach that incorporates distributive justice, the ethics of care, and a gender perspective. Nursing can play a key role in transforming the healthcare model towards one that is more inclusive, dignified, and focused on equity. This study reveals how relational injustice and epistemic exclusion shape the healthcare experiences of people affected by homelessness, challenging nurses to act as moral agents in restoring recognition and dignity.