John R. Stone

Healthcare Inequality, Cross-Cultural Training, and Bioethics: Principles and Applications

To promote so-called cultural competence in work of direct-care providers and other health professionals among diverse peoples, cross-cultural training (CCT) is now widely advised. However, in ethically assessing aims and content of CCT, and surrounding issues and concerns, what should guide us? And if we can elaborate satisfactory moral touchstones, what do they imply for healthcare professionals, overarching structures, and bioethicists? Building on prior work, this paper tries to help answer these questions. Work in this paper is indebted to discussions with Annette Dula, Insoo Hyun, Muhjah Shakir, Melanie Tervalon, and colleagues at Tuskegee University and the Tuskegee University National Center for Bioethics in Research and Healthcare. Erika Blacksher, Leonard Ortmann, and Madison Powers provided useful comments about earlier drafts. This work was supported by CDC Cooperative Agreement Number P76/CCP424229-2.

Saving and Ignoring Lives: Physicians’ Obligations to Address Root Social Influences on Health—Moral Justifications and Educational Implications

The predominant influences on health are social or upstream factors. Poverty, inadequate education, insecure and toxic environments, and inferior opportunities for jobs and positions are inequitable disadvantages that adversely affect health across the globe. Many causal pathways are yet to be understood. However, elimination of these social inequalities is a moral imperative of the first order. Some physicians by word and deed argue that medical doctors should oppose the “structural violence” of social inequalities that greatly shorten lives and wreak so much suffering.

An Ethical Framework for Community Health Workers and Related Institutions

The aim of this article is to provide practical ethical guidance and to foster further critical reflection on ethical issues in the work, education, and training of community health workers. The analysis includes implications for associated institutions. We first summarize the roles of community health workers and some evaluations of their work. After next highlighting ethical elements from the literature, we then give a justification for the ethical framework that follows. The article then provides a detailed discussion of a set of basic ethical principles for the field of community health work. Among the principles, we argue that the following 3 should have a foundational role: equal and substantial respect, justice, and care. Among these, respect is most fundamental.

Promoting Community Health and Eliminating Health Disparities Through Community-Based Participatory Research

In physical therapy, there is increasing focus on the need at the community level to promote health, eliminate disparities in health status, and ameliorate risk factors among underserved minorities. Community-based participatory research (CBPR) is the most promising paradigm for pursuing these goals. Community-based participatory research stresses equitable partnering of the community and investigators in light of local social, structural, and cultural elements. Throughout the research process, the CBPR model emphasizes coalition and team building that joins partners with diverse skills/expertise, knowledge, and sensitivities. This article presents core concepts and principles of CBPR and the rationale for its application in the management of health issues at the community level. Community-based participatory research is now commonly used to address public health issues. A literature review identified limited reports of its use in physical therapy research and services. A published study is used to illustrate features of CBPR for physical therapy. The purpose of this article is to promote an understanding of how physical therapists could use CBPR as a promising way to advance the professions goals of community health and elimination of health care disparities, and social responsibility. Funding opportunities for the support of CBPR are noted.

Elderly and Older Racial/Ethnic Minority Healthcare Inequalities Care, Solidarity, and Action

The elderly and older racial/ethnic minorities may often receive inferior healthcare even if they have good access to evidence-based interventions. Premature death and preventable losses of quality of life are probable outcomes. Elderly individuals may be less frequently provided the best data-supported healthcare simply because they are old. Bias or prejudice against the aged may be a significant cause. Underrepresentation of the elderly in biomedical research is another factor. The problem is international. In their account of social justice, Madison Powers and Ruth Faden have plausibly argued that society should especially ensure the health of the young, because failures of early childhood development are often irreversible. Hence, withholding some effective healthcare from the elderly could be ethically justified in an overall fair allocation system. Major bioethical attention has deservedly been given to such macro age-group issues. It is quite different to withhold effective healthcare to specific individuals merely because they are old and not because of decisions reached by a fair process and sound ethical considerations. Christine Cassel calls this ‘‘implicit rationing’’ that has ‘‘no legitimacy.’’ Such inequitable care requires much greater attention. This article aims to help meet the need.

Racism and Bioethics: Experiences and Reflections.

Marion Danis, Yolonda Wilson, and Amina White argue correctly that “Bioethicists Can and Should Contribute to Addressing Racism” (2016). My daily bioethics work involves racism–health intersections through teaching, programs, scholarship, and collaboration. Health and health care equity are the focus. Complex and often challenging, the work involves knowledge, skills, strategies, and experiences far beyond my original experiences, medical background, and philosophical/bioethical education and skills. I hope the following remarks help bioethicists venturing into “racism work.” My grandparents, Ukrainian Jewish immigrants and Pennsylvania White Protestant farmers, link me to oppression, discrimination, genocide/murder, injustice, hard work, humility, and privilege. Slowly appreciating this grounding and connections with racism, in 1999 I joined the newly formed Tuskegee University National Center for Bioethics in Research and Health (TUNCB) while completing a PhD in philosophy with a justice and bioethics focus. The Alabama move followed earlier practice in cardiology (mostly western Montana) and philosophical study, one course at a time. In 2006 I joined Creighton University’s Center for Health Policy and Ethics in Omaha, NE. I am a professor in the School of Medicine and core faculty in our Master of Science Program in Health Care Ethics.

Commentary: Ethics and Medical Judgment: Whose Values? What Process?

404 users should be given a lower priority for treatment than others. However, to operate fairly, this policy should be transparent rather than covert. And even then, it would be extremely diffi cult to decide which lifestyle criteria to operate. Even if one could, in theory, operate such a system, it would soon become enormously complicated and arbitrary. Besides, it is clear that this patient is in great need, and need should be a paramount consideration. This brings us back to the difference the possible treatments would make to his prognosis. This question is particularly pertinent with respect to the LVAD. Can the cardiologist really say that such a treatment would be entirely futile, due to Mr. H’s drug history? It is possible that Mr. H has already damaged his heart so much by his drug use that a LVAD would be of no signifi cant net benefi t to him— even if he abstains from drugs in the future. But another possibility is that, although a LVAD would be of signifi cant net benefi t if he remains permanently abstinent, his chances of remaining abstinent are judged to be low. A history of repeated relapse might be considered good grounds for this prediction. If the decision not to offer LVAD is based on a prediction of future harmful drug use, the team needs to be very sure that this prediction is well grounded, given the enormous harm—the patient’s decline and death—that the treatment might prevent. It is, I suspect, very hard to make accurate predictions of a patient’s prospects of abstinence or relapse. Mr. H’s presumed insights into addiction are probably not suffi cient to prevent relapse, because relapse is (arguably) a conscious choice to use drugs again, for the pleasure it brings, in spite of knowing the dangers. At the same time, we must remember that many people do recover from serious addictions, because they eventually decide that enough is enough. If or when Mr. H becomes aware of the very serious threat to his life that his drug use poses, we cannot rule out that he will make this decision. A further important point is that expected treatment/nontreatment outcomes lie on a continuum, whether in terms of likelihood and/or degree of benefi t. If Mr. H has a 50 percent chance of signifi cant, even if suboptimal, benefi t from treatment, this should be taken seriously, especially if the alternative is a likely early death. I suggest then that, at the very least, the LVAD be given to Mr. H. If he recovers his competence to make decisions, the treatment may give him time to consider the gravity of the situation he is in, and perhaps to plan abstinence from drugs more decisively than previously. In view of this possibility, and the poor prognosis without treatment, this is the least the team can do.

Non-payment and non-care: Ethics and continuity of care

In this issue of Medical Care we learn that primary care physicians would often withhold a range of services to a hypothetical patient who has not paid what is owed them. With less, but still substantial frequency, they have actually withheld the same services. These actions comprise discontinuity of care and patient abandonment. As the authors of the study note, such refusal of services violates physicians’ obligations in their social contract to put patient’s health above other interests, moral guidelines promulgated by prominent medical professional organizations, and physicians’ fiduciary obligations to patients. My comments will amplify the ethical analysis and then suggest implications for medical education. The first step is to sketch background factors regarding justice and social influences on health.

Commentary: Mrs. J—Culture and Healthcare Ethics Committees

The heart-rending story of Mrs. J raises many complex ethical issues. Key elements include suffering, disagreement, culture, religion, perspective, and facts. Overarching concerns include whose voices and stories should count, the connection of pain with suffering, and how healthcare ethics committees should respond.