Ethics and Healthcare for African Americans

1
Ethics and Healthcare for African Americans

• John R. Stone, MD, PhD
• Center for Health Policy and Ethics
• Creighton University Medical Center
• JohnStone_at_creighton.edu
• http//chpe.creighton.edu/chpe/stone.htm
• June 1, 2007

2
Purpose

• Summarize important themes and ethical issues in
  healthcare of African Americans
• Give some broad practical applications

3
Driving Issue

• Significant inequalities in health and healthcare
  that adversely affect African Americans

4
Black Diversity

• History
• Beliefs
• National backgrounds
• Customs

Melissa Welch. Care of Blacks and African
Americans. In Cross-Cultural Medicine. edit. by
Judyann Bigby. American College of Physicians
2003, pp. 29-60.
5
Special Emphasis

• Trust and trustworthiness
• Respect

6
Dont Touch

• She You dont want to touch me.
• She was giving me change.
• She Black.
• Stone White.
• She 20
• Stone. 28, USPHS medical officer
• Year 1970 or 1971
• Place Galveston Texas.

7
Demanding? Hostile?

• White patients
• Demanding
• Needs met
• Black patients
• Hostile
• Needs not met, or less well

8
Key Background

• Pervasive inequalities, generally unjust
• Health
• Healthcare
• IOM 2003 (http//www.nap.edu/books/030908265X/html
  /)
• NHDR 2005 (http//www.ahrq.gov/qual/nhdr05/nhdr05.
  pdf)
• Life Expectancy 1983-2003 (Harper S, Lynch J,
  Burris S, Smith GD. Trends in the Black-White
  Life Expectancy Gap in the United States,
  1983-2003. JAMA. 20072971224-1232.)

9
Crucial Intersections-AA Healthcare
People
Principle
10
B/W Life Expectancy Gap
Harper S, Lynch J, Burris S, Smith GD. Trends in
the Black-White Life Expectancy Gap in the United
States, 1983-2003. JAMA. 20072971224-1232. From
the United States Life Tables of the National
Center for Health Statistics.
11
B/W Life Expectancy _at_ Birth
Harper S, Lynch J, Burris S, Smith GD. Trends in
the Black-White Life Expectancy Gap in the United
States, 1983-2003. JAMA. 20072971224-1232. From
the United States Life Tables of the National
Center for Health Statistics.
12
Racial/EthnicHealthcare Inequalities

• Given extensive evidence of healthcare
  inequalities by R/E.
• Is your institution assessing care by R/E?
• Evidence constitutes an imperative for careful
  assessment and remediation.
• Should the ethics committee be involved? Why?
  How?
• What should individual professionals do?

13
R/E HealthcareEthical Principles

• Respect (equal, substantial)
• Justice
• Care
• Community

Stone JR. Healthcare Inequality, Cross-Cultural
Training, and Bioethics Principles and
Applications, Accepted for publication in
Special Section of Cambridge Quarterly of
Healthcare Ethics Illuminating Culture, Health,
and Ethics Beyond Equality and Justice. 2008 17
(2), Spring. Stone JR, Parham, GP. An Ethical
Framework for Community Health Workers and
Related Institutions. Accepted for publication in
Family Community Health Journal. Spring/early
fall 2007. Issue 304.
14
R/E Healthcare InequalitiesWhy Institutions May
Not Assess

• Beliefs R/E bias, stereotypes--none/trivial
• Fears negative publicity litigation
• Resources takes them
• Threatening talk about race and racism
• Strong responses take moral courage

Dula A and Stone JR. Wakeup Call Healthcare and
Racism. Hastings Center Report,
2002 32(4)48.
15
Dont Touch

• She You dont want to touch me.
• She was giving me change.
• She Black.
• Stone White.
• She 20
• Stone. 28, USPHS medical officer
• Year 1970 or 1971
• Place Galveston Texas.

16
Crucial Intersections
People
Principle
17
African AmericansHealth, Healthcare, and Ethics
Social Determinants
HC Structures
Pt-Prof
Focus of Ethics Committees? Focus of Health
Professionals?
18
Demanding? Hostile?

• White patients
• Demanding
• Needs met
• Black patients
• Hostile
• Needs not met, or less well

19
Issues Cross-cultural and More

• Whiteness
• Openness to anger, hostility
• Sensitivity to being labeled racist
• Humility that could be racially biased
• Intending equal care ? equal care
• Equal care ? color-blind care
• Historical knowledge and sensitivity

20
Information RelationshipsWhite/Black

• Focus groups patients with cardiac stress
  testing
• Perception of information provided equivalent.
  (incomplete, vague, ambiguous, and unclear.
• Blacks preference for building a relationship
  with physicians (trust) before agreeing to an
  invasive cardiac procedure, and just as
  consistently complained that trust was lacking.
• Whites tended to emphasize that they were
  inadequately convinced of the need for
  recommended procedures.
• Tracie C. Collins, Jack A. Clark, Laura A.
  Petersen, Nancy R. Kressin. Racial Differences in
  How Patients Perceive Physician Communication
  Regarding Cardiac Testing. Medical Care.
  200240(1S) I-2734.

21
Trust and Healthcare of African Americans

• Trust and Trustworthiness
• Long and sordid history
• Rational Distrust
• Fallibility Assumption
• Trustworthiness primary

Gamble, V. N. (2006). Trust, Medical Care, and
Racial and Ethnic Minorities. Multicultural
Medicine and Health Disparities. D. Satcher and
R. J. Pamies. New York, McGraw-Hill 437-448.
22
Sources of Distrust

• Perceptions that physician communication was
  less supportive, less partnering, and less
  informative accounted for black patients lower
  trust in physicians.
• Our findings also raise the question about
  whether there was variation in actual physician
  communication behaviors by race of patient,
  whether patients interpreted the communication
  behavior differently by race, or both.
• Gordon HS. Street RL Jr. Sharf BF. et al.
  Racial differences in trust and lung cancer
  patients' perceptions of physician communication.
  J Clin Oncol. 200624(6) 904-9.

23
Preference or Trust?

• Mrs. P, AA early-stage endometrial cancer
• No evidence of metastasis.
• Vaginal bleeding stops after curettage.
• Gyn oncologist recommends hysterectomy. Says he
  has performed hundreds of these operations in the
  last several years and that the risks are very
  low.
• Mrs. P notices women in the waiting room look
  very ill.
• She does not return to the doctor or return
  calls.
• K Armstrong, C Hughes-Halbert, DA Asch. Patient
  Preferences Can Be Misleading as Explanations for
  Racial Disparities in Health Care. Arch Intern
  Med. 2006166950-954.

24
Trust/Trustworthiness

• Case African American person has a serious
  health condition. Doctor informs that
  interventions A, B, and C are reasonable, but
  recommends A. Doctor gives briefly summarizes why
  recommends A. Patient raises several complicated
  questions. The doctor answers them. More
  questions. Doctor you should just trust me.

25
Distrust, History, Racial Experience

• Knowledge of how African Americans have been
  treated and their continued experiences is a step
  toward
• Understanding rational distrust
• Empathizing with those who distrust
• Being open to and patient with distrust
• Personal transformation
• Building trustworthiness
• Building trust

26
Distrust and Resource Costs

• Extended care at end-of-life
• Increased litigation
• DeVille, Kenneth Kopelman, Loretta M.
  Diversity, Trust, and Patient Care Affirmative
  Action 25 Years after Bakke. J Med Philos.
  200328(4)489-516.

27
Building Rational TrustClinical Interactions

• Respect
• Honesty
• Competency
• Transparency
• Humanistic caring
• Sustained patient-physician relationships
• Openness to variety

• Cross-cultural knowledge, sensitivity, humility,
  and agency enhancement
• Decision-sharing (cultural variation)
• Diverse workforce
• Insufficient empirical guidance

• K Armstrong, C Hughes-Halbert, DA Asch. Patient
  Preferences Can Be Misleading as Explanations for
  Racial Disparities in Health Care. Arch Intern
  Med. 2006166950-954.
• McKinstry B, Ashcroft RE, Car J. Interventions
  for improving patients' trust in doctors and
  groups of doctors. Cochrane Database Syst Rev.
  20063 CD004134.

28
Building Rational Trust Institutions

• Trustworthiness Focus (Radical change?)
• Major Community Involvement Pervasive
• Develop comprehensive training programs
  cross-cultural, respect, humility, power-sharing,
  agency-enabling
• Assess outcomes
• Diversify workforce all levels
• (See advice for clinical interactions)

See Gamble, V. N. (2006). Trust, Medical Care,
and Racial and Ethnic Minorities. Multicultural
Medicine and Health Disparities. D. Satcher and
R. J. Pamies. New York, McGraw-Hill 437-448.
29
Forms of AddressSeparate Cases

• HC Professional Good morning Sadie.
• Ms. Sadie Robinson is 75 years old
• HC Professional to family member Lets get you a
  chair.
• HC Professional to family What do you people
  think would be best for Mr. Taylor?
• HC Professional avoids touching

30
RespectEqual, Substantial, Particular

• Names
• Touch
• Recognition
• Regard
• Agency
• Passion and caring
• Sitting and listening

31
Real Case

• Betty (40, healthcare worker)
• I went to this doctor for a pap smear. I had
  an infectionShe said, How many sex partners to
  do you have? I said Gulp and just looked at
  herShe said, Oh, you dont know how many.I
  felt like was a little piece of garbage. I was
  juststereotyped There was a little black woman
  whos out havin all of these men who comes in
  here with an infection

Melissa Welch. Care of Blacks and African
Americans. In Cross-Cultural Medicine. edit. by
Judyann Bigby. American College of Physicians
2003, p 32.
32
Preferences? Respect?

• Mrs. S, AA, 65, routine checkup, different
  doctor.
• Near conclusion told needs flu shot, nurse will
  give
• Mrs. S is unsure friends say flu shots make them
  sick.
• Doc leaves before Mrs. S can question.
• At checkout, Mrs. S declines the flu shot, marked
  as refusing.
• Did her refusal represent her preference?
• Blacks and Hispanics report worse communication
  than Whites
• Whites get more information
• K Armstrong, C Hughes-Halbert, DA Asch. Patient
  Preferences Can Be Misleading as Explanations for
  Racial Disparities in Health Care. Arch Intern
  Med. 2006166950-954.

33
Respect

• Quality attention
• Openness (heart, mind)
• Willingness to be vulnerable
• Deep/authentic curiosity
• Grows out of
• Mutuality
• Connection
• Engagement

• Honor
• Boundaries
• Privacy

Sarah Lawrence-Lightfoot. Respect An
Exploration. Cambridge, MA Perseus 2000, pp.
217, 224
34
Who are you?Default Assumptions

• Are you just another privileged, ignorant,
  prejudiced professional?...or not?
• Do you really care about me?.......or not?
• Do you respect me?........or not?

Professional Institution
35
Respect
36
Healthcare InequalitiesCross-cultural education
training

• Widely advised
• Minimal outcome data

37
Promoting Institutional Change

• Advocacy
• Professionals
• Communities
• Law
• Ethics Committees

38
Prejudice Stereotypes Doctors

• Dont think they are prejudiced
• Dont believe stereotypes affect choices
• But unconscious prejudice and stereotypes can
  influence choices.
• Become mindful that have biases stereotypes
  that may affect decisions
• Be alert time pressure promotes reliance on
  prejudice and stereotypes
• Be mindful of negative responses

Smith WR, Busey-Jones J. et al. (2006). Case
Studies in Multicultural Medicine and Health
Disparities. Multicultural Medicine and Health
Disparities. D. Satcher and R. J. Pamies. New
York, McGraw-Hill 361-388.
39
Crucial Intersections
People
Principle
40
References Cited

• Melissa Welch. Care of Blacks and African
  Americans. In Cross-Cultural Medicine. edit. by
  Judyann Bigby. American College of Physicians
  2003, pp. 29-60.
• IOM 2003 (http//www.nap.edu/books/030908265X/html
  /)
• NHDR 2005 (http//www.ahrq.gov/qual/nhdr05/nhdr05.
  pdf)
• Life Expectancy 1983-2003 (Harper S, Lynch J,
  Burris S, Smith GD. Trends in the Black-White
  Life Expectancy Gap in the United States,
  1983-2003. JAMA. 20072971224-1232.)
• Harper S, Lynch J, Burris S, Smith GD. Trends in
  the Black-White Life Expectancy Gap in the United
  States, 1983-2003. JAMA. 20072971224-1232. From
  the United States Life Tables of the National
  Center for Health Statistics.
• Stone JR. Healthcare Inequality, Cross-Cultural
  Training, and Bioethics Principles and
  Applications, Accepted for publication in
  Special Section of Cambridge Quarterly of
  Healthcare Ethics Illuminating Culture, Health,
  and Ethics Beyond Equality and Justice. 2008 17
  (2), Spring.
• Stone JR, Parham, GP. An Ethical Framework for
  Community Health Workers and Related
  Institutions. Accepted for publication in Family
  Community Health Journal. Spring/early fall
  2007. Issue 304.
• Dula A, Stone JR. Wakeup Call Healthcare and
  Racism. Hastings Centr Report, 2002 32(4)48.
• Tracie C. Collins, Jack A. Clark, Laura A.
  Petersen, Nancy R. Kressin. Racial Differences in
  How Patients Perceive Physician Communication
  Regarding Cardiac Testing. Medical Care.
  200240(1S) I-2734.
• Gamble, V. N. (2006). Trust, Medical Care, and
  Racial and Ethnic Minorities. Multicultural
  Medicine and Health Disparities. D. Satcher and
  R. J. Pamies. New York, McGraw-Hill 437-448.
• Gordon HS. Street RL Jr. Sharf BF. et al. Racial
  differences in trust and lung cancer patients'
  perceptions of physician communication. J Clin
  Oncol. 200624(6) 904-9.
• K Armstrong, C Hughes-Halbert, DA Asch. Patient
  Preferences Can Be Misleading as Explanations for
  Racial Disparities in Health Care. Arch Intern
  Med. 2006166950-954.
• Sarah Lawrence-Lightfoot. Respect An
  Exploration. Cambridge, MA Perseus 2000, pp.
  217, 224.
• Smith WR, Busey-Jones J. et al. (2006). Case
  Studies in Multicultural Medicine and Health
  Disparities. Multicultural Medicine and Health
  Disparities. D. Satcher and R. J. Pamies. New
  York, McGraw-Hill 361-388.