It is urgent that we address the causes and harmful effects of racism in health care. We propose that building diversity competence in the way we deliver health care services is key to this effort....

This narrative provides insight into medical education for Black physicians in South Carolina in the 1960s, during the civil rights movement. It also discusses the many rewards and challenges of being a physician of color, describes what has been done to develop programs that benefit minority communities, and argues that more such programs are needed.

If you are black, you are more likely to get inferior health care than if you are white. And if you are Hispanic or Native American, odds are you're also in trouble. So finds the Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.

Earp et al. provide a robust justification for the decriminalization of drugs based on the systemic racism that fuels the “war on drugs” and the ongoing harms of drug policies to individuals...

Attending to racism and US bioethics raises the question of whether and how racism in bioethics has been the subject of bioethical scrutiny. Bioethics has certainly brought its analytical tools to bear on racist aspects of clinical care and biomedical research. But has bioethics studied racism in bioethics as its subject? A close examination of relevant reports, articles, and books in the US bioethics literature published in the early days of the field, pre-2000, shows mixed findings. (...) In the 1970s, racism as a bioethical concern was variously nonexistent, vaguely implied, and powerfully examined and condemned. In the late 1980s/early to mid-1990s, racism was more frequently described and critiqued, often in the context of discussions about African American perspectives of biomedical ethics and inequities in health care. Understanding how racism in bioethics has been addressed as an ethical concern has consequences for the historical narratives told about the field, for antiracist bioethics work today, and for envisioning an antiracist future for bioethics. (shrink)

This article examines how people of color can biologically inherit the deleterious effects of white racism. Drawing primarily on the field of epigenetics, I demonstrate how transgenerational racial disparities are in fact racist disparities that can be manifest physiologically, helping constitute the chemicals, hormones, cells, and fibers of the human body. Epigenetics can be used to demonstrate how white racism can have durable effects on the biological constitution of human beings that are not limited to the specific person (...) who is the target of white racism, but instead extend to that person's offspring. In this way, the field of epigenetics can help philosophers and others understand the transgenerational biological impact of social forces such as white racism. It reveals that the damage done by white racism is more extensive than critical philosophers of race might have realized, and also that interventions against white racism must address not just the economic, geographical, social, and psychological, but also the biological aspects of human existence. In particular, the article examines racist disparities in preterm birth rates and argues that the scope and significance of prenatal care for African American women must be expanded intergenerationally and include wide-scale forms of racial justice. (shrink)

Racism is a pervasive issue in patient care and a key social determinant of health. Clinical ethicists, like others involved in patient care, have a duty to recognize and respond to racism on both individual and systems-wide levels to improve patient care. Doing so can be challenging and, like other skills in ethics consultation, may benefit from specialized training, standardized tools and approaches, and practice. Learning from existing frameworks and tools, as well as building (...) new ones, can help guide clinical ethicists to systematically approach racism as it affects clinical cases. Here, we propose an expansion of the commonly used four-box method to clinical ethics consultation, where racism is considered as a potential factor in each of the four boxes. We apply this method to two clinical cases to highlight ethically salient information that might be missed using the standard formulation of the four boxes but captured with the expanded version. We argue that this expansion of an existing clinical ethics consultation tool is ethically justified insofar as it (a) creates a more just approach, (b) supports individual consultants and services, and (c) facilitates communication in contexts where racism impinges on effecting good patient care. (shrink)

My assigned task in today’s colloquium is to review philosophers’ perspectives on the broad question of whether health care rationing ought to target the elderly. This is a revolutionary question, particularly in a society that is so sensitive to apparent discrimination, and the question must be approached carefully if it is to be successfully dealt with. Three subordinate questions attend this one and must be addressed in the course of answering it. The first such question has to do (...) with the issue of justice: how is it fair to target the elderly in achieving reductions in health care costs? Isn’t the proposal, or for that matter, isn’t targeting any age group, morally objectionable as a species of ageism, just as targeting members of a particular race or sex would be racist or sexist? The second subordinate question has to do with the issue of fittingness. Given that we can show in some way that targeting the elderly is not inherently unjust, why would limiting health care to them be a fitting thing for medicine to do? How would it fit, for example, with the traditional commitments of medicine, to sustain life, to relieve suffering, to heal and cure and restore function? And in particular, if medicine has the ability to save and relieve and restore the elderly, why should it replace that set of commitments with a different set for this particular population? The third subordinate question seems political, an arena reserved for one of my speaker colleagues today. There are, I believe, some underlying philosophical dimensions to its answer, and so I will say something about it. The philosophical/political questions is, Given that rationing health care to the elderly is not patently unjust, and given that a case can be made out that the ends of medicine are not violated by such limitation, shy should the elderly, as a group, assent to such a limitation? I want to address these subordinate questions, for I believe them to be the chief stumbling blocks for the possibility of an affirmative answer to our... (shrink)

Many health care organizations made public commitments to become antiracist in the wake of George Floyd's murder. These actions raise questions about the appropriateness of health care's engagement in racial justice and social justice movements generally. We argue that health care organizations can be usefully thought of as having two roles: a functional role to care for the sick and a meta‐role as an organizational citizen. Fulfilling the role of citizen may require participating (...) in the pursuit of social justice, including efforts to achieve racial equity. The demands of these two roles will need to be balanced, but the role of organizational citizen has been largely ignored and merits serious attention. (shrink)

In colonial societies such as Canada the implications of colonialism and ethnocide (or cultural genocide) for ethical decision‐making are ill‐understood yet have profound implications in health ethics and other spheres. They combine to shape racism in health care in ways, sometimes obvious, more often subtle, that are inadequately understood and often wholly unnoticed. Along with overt experiences of interpersonal racism, Indigenous people with health care needs are confronted by systemic racism in the (...) shaping of institutional structures, hospital policies and in resource allocation decisions. Above all, racism is a function of state law – of the unilateral imposition of the settler society law on Indigenous communities. Indeed, the laws, including health laws, are social determinants of the ill‐health of Indigenous peoples. This article describes the problem of Indigenous ethnocide and explores its ethical implications. It thereby problematizes the role of law in health ethics. (shrink)

In the midst of extreme and dualistic religio-political debates regarding women’s sexual wellness and abortion, one begins to wonder what a new theo-ethical approach might look like which rejects overly-simplistic, harmful understandings of such crucial issues. What might it look like to truly centre women’s full human experiences, loving each other in a way that addresses harm and meets tangible needs? This article examines the complex inequitable structural and institutional realities of sexual wellness and abortion through an intersectional theo-ethical lens. (...) The article then proceeds to suggest a new socio-religio-political ‘Pro-Love’ philosophy, undergirded by foundational theological understandings of justice-oriented love, and situated within the broad fields of Feminist, Liberation, Process, and Queer Theologies, within the Christian tradition. The suggested approach requires systematically addressing root issues affecting the lack of equitable access to sexual wellness and the racist/sexist/classist structures forcing women into under-resourced and unsafe environments, leading to high demand for abortion services. (shrink)

Hastings Center Report, Volume 52, Issue S1, Page S46-S49, March‐April 2022.

The purpose of cultural competence education for medical professionals is to ensure respectful care and reduce health disparities. Yet as Berger and Miller (2021) show, the cultural competence framework is dated, confused, and self-defeating. They argue that the framework ignores the primary driver of health disparities—systemic racism—and is apt to exacerbate rather than mitigate bias and ethnocentrism. They propose replacing cultural competence with a framework that attends to two social aspects of structural inequality: health and (...) social policy, and institutional-system activity; and two psychological aspects of structural inequality: the clinical encounter, and the epistemic. -/- We agree with the structural approach. To that end, we think it would be fruitful to include attention to physical contributors to structural inequality, namely the material artifacts used in medicine. Devices, tools, and technologies can materialize biases, perpetuate oppression, and contribute to health disparities. Granted, not everything that interests philosophers can be squeezed into medical education. Nevertheless, there are compelling reasons for including the study of material artifacts in education designed to reduce health disparities. First, devices and tools often carry forward biases from the past, and keep biases hidden from plain sight. Second, by studying these artifacts, future clinicians can begin to see themselves as part of a larger sociotechnical system. Finally, as medicine becomes increasingly tech-laden, it’s important for clinicians to see how material artifacts (including algorithms) connect individuals to structures. This will help to undermine oversimplified narratives according to which objective tools and technologies can correct for the bias and subjectivity of flawed human beings. (shrink)

This volume addresses whether, how, and where laws (variously defined) teach values and shape moral character in late modern liberal societies. Each author recognizes the essential value of state law in fostering peace, security, health, education, charity, trade, democracy, constitutionalism, justice, and human rights, among many other moral goods. Each author also recognizes, however, the grave betrayals of law in supporting fascism, slavery, apartheid, genocide, persecution, violence, racism, and other forms of immorality and injustice. They thus call for (...) state laws that set a basic civil morality of duty for society and for robust freedoms that protect private individuals and private groups to cultivate a higher morality of aspiration"--Back cover. (shrink)

Precision medicine is an emerging approach to individualized care. It aims to help physicians better comprehend and predict the needs of their patients while effectively adopting in a timely manner the most suitable treatment by promoting the sharing of health data and the implementation of learning healthcare systems. Alongside its promises, PM also entails the risk of exacerbating healthcare inequalities, in particular between ethnoracial groups. One often-neglected underlying reason why this might happen is the impact of structural (...) class='Hi'>racism on PM initiatives. Raising awareness as to how structural racism can influence PM initiatives is paramount to avoid that PM ends up reproducing the pre-existing health inequalities between different ethnoracial groups and contributing to the loss of trust in healthcare by minority groups. We analyse three nodes of a process flow where structural racism can affect PM’s implementation. These are: the collection of biased health data during the initial encounter of minority groups with the healthcare system and researchers, the integration of biased health data for minority groups in PM initiatives and the influence of structural racism on the deliverables of PM initiatives for minority groups. We underscore that underappreciation of structural racism by stakeholders involved in the PM ecosystem can be at odds with the ambition of ensuring social and racial justice. Potential specific actions related to the analysed nodes are then formulated to help ensure that PM truly adheres to the goal of leaving no one behind, as endorsed by member states of the United Nations for the 2030 Agenda for Sustainable Development. Structural racism has been entrenched in our societies for centuries and it would be naïve to believe that its impacts will not spill over in the era of PM. PM initiatives need to pay special attention to the discriminatory and harmful impacts that structural racism could have on minority groups involved in their respective projects. It is only by acknowledging and discussing the existence of implicit racial biases and trust issues in healthcare and research domains that proper interventions to remedy them can be implemented. (shrink)

This chapter examines the ways race should and should not affect the delivery of health care benefits in a system that is just. To show how race affects the distribution of health care, it highlights disquieting similarities between the infamous Tuskegee study of fifty years ago and contemporary public health efforts directed at reducing HIV infection/AIDS in the African-American community that may detract from the effectiveness of these programs. It argues that a just society’s stability (...) may require resource allocation for the purpose of demonstrating the extent of justice in the system. Furthermore, patients’ trust in their physicians is important to good health care and distrust is a disadvantage in obtaining effective health care. The chapter also proposes a series of remedies. In an illustrative postscript, it considers Michelle Obama’s initiative to reduce the incidence of obesity in U.S. children and contends that, given the history of anti-black racism in America, African Americans still have special reasons to distrust programs that would alter their eating habits and lifestyles. (shrink)

This paper offers a critical commentary on the essentialist concept of ethnicity, which, it is argued, underpins the discourse of transcultural health‐care. Following a consideration of the difficulties that ensue from the way in which ethnicity has been theorised within transcultural nursing in particular, the paper turns to a consideration of alternative ways of thinking about ethnicity, which have emerged from more recent social anthropology and postmodernism. It addresses the question of how to therorise ethnicity in a way (...) that does not entail its reification as a set of fixed cultural properties, and makes some tentative suggestions for the possibility of a critical culturalist approach to difference and healthcare practice, which must include a consideration of racisms. (shrink)

This book clarifies the distinctions between three key concepts - Anti-Racist Practice (ARP), Anti-Discriminatory Practice(ADP) and Anti-Oppressive Practice (AOP). Critically and constructively analysing these three approaches to practice it reappraises their potential in the light of emerging equality issues in the health service. With contributions from leading teachers and practitioners in the field, Equalising Opportunities provides students and practitioners in health and social care with a clear overview of an area where there is much confusion and imperfect (...) understanding. (shrink)

This is a study involving three HIV clinics in the Canadian provinces of Newfoundland and Labrador, and Manitoba. We sought to identify ethical issues involving health care providers and clinic clients in these settings, and to gain an understanding of how different ethical issues are managed by these groups. We used an institutional ethnographic method to investigate ethical issues in HIV clinics. Our researcher conducted in-depth semi-structured interviews, compiled participant observation notes, and studied health records in order (...) to document ethical issues in the clinics, and to understand how health care providers and clinic clients manage and resolve these issues. We found that health care providers and clinic clients have developed work processes for managing ethical issues of various types: conflicts between client-autonomy and public health priorities, difficulties associated with the criminalization of nondisclosure of HIV positive status, challenges with non-adherence to HIV treatment, the protection of confidentiality, barriers to treatment access, and negative social determinants of health and well-being. Some ethical issues resulted from structural disadvantages experienced by clinic clients. The most striking findings in our study were the negative social determinants of health and well-being experienced by some clinic clients – such as experiences of violence and trauma, poverty, racism, colonization, homelessness, and other factors affecting well-being such as problematic substance use. These negative determinants were at the root of other ethical issues, and are themselves of ethical concern. (shrink)

DUREY A, WYNADEN D, THOMPSON SC, DAVIDSON PM, BESSARAB D and KATZENELLENBOGEN JM. Nursing Inquiry 2012; 19: 144–152 [Epub ahead of print]Owning solutions: a collaborative model to improve quality in hospital care for Aboriginal AustraliansWell‐documented health disparities between Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal) and non‐Aboriginal Australians are underpinned by complex historical and social factors. The effects of colonisation including racism continue to impact negatively on Aboriginal health outcomes, despite being under‐recognised and (...) under‐reported. Many Aboriginal people find hospitals unwelcoming and are reluctant to attend for diagnosis and treatment, particularly with few Aboriginal health professionals employed on these facilities. In this paper, scientific literature and reports on Aboriginal health‐care, methodology and cross‐cultural education are reviewed to inform a collaborative model of hospital‐based organisational change. The paper proposes a collaborative model of care to improve health service delivery by building capacity in Aboriginal and non‐Aboriginal personnel by recruiting more Aboriginal health professionals, increasing knowledge and skills to establish good relationships between non‐Aboriginal care providers and Aboriginal patients and their families, delivering quality care that is respectful of culture and improving Aboriginal health outcomes. A key element of model design, implementation and evaluation is critical reflection on barriers and facilitators to providing respectful and culturally safe quality care at systemic, interpersonal and patient/family‐centred levels. Nurses are central to addressing the current state of inequity and are pivotal change agents within the proposed model. (shrink)

Law and racism are intertwined, with legal tools bearing the potential to serve as instruments of oppression or equity. This Special Issue explores this dual nature of health law, with attention to policing in the context of mental health, schools, and substance use disorders; industry and the environment in the context of food advertising, tobacco regulation, worker safety, and environmental racism; health care and research in the context of infant mortality, bias in medical applications (...) of AI, and diverse inclusion in research; and anti-racist teaching and practice in the context of building an interprofessional curriculum and medical-legal partnerships. (shrink)

The pandemic reveals; the novel coronavirus pandemic has brought the historically rooted inequities of our society to the forefront. We argue that an intersectional analysis is needed to further help peel back the veil that the pandemic has begun to reveal. We identify structural gendered racism—the totality of interconnectedness between structural racism and structural sexism in shaping race and gender inequities—as a root cause of health problems among Black women and other women of color, which has been (...) amplified during the pandemic. We show that women of color occupy disadvantaged positions within households, occupations, and health care institutions, and therefore face heightened risk for COVID-19 and lowered resources for mitigating the impact of the deadly virus. Intersectional analyses and solutions must be centered to also reveal, we hope, a new way forward. (shrink)

The COVID-19 pandemic has had a global effect. The disproportionate impact on Indigenous peoples and racialized groups has brought ethical challenges to the forefront in research and clinical practice. In Canada, the Tri-Council Policy Statement (TCPS2), and specifically the principle of justice, emphasizes additional care for individuals “whose circumstances make them vulnerable”, including Indigenous and racialized communities. In the absence of race-based data to measure and inform health research and clinical practice, we run the risk of causing more (...) harm and contributing to ongoing injustices. However, without an accepted framework for collecting, maintaining, and reporting race-based data in Canada, more guidance is needed on how to do this well. Importantly, a framework for collecting race-based data should build on existing guidance from Indigenous and other structurally marginalized communities, the TCPS2, recommendations from the World Health Organization, and involve relevant stakeholders. In this paper, we describe historical examples of unethical studies on Indigenous and racialized groups, discuss the challenges and potential benefits of collecting race-based data, and conclude with objectives for a pan-Canadian framework to inform how race-based data is collected, stored, and accessed in health research. (shrink)

Ethics consultation has become an integral part of the fabric of U.S. health care delivery. This article summarizes the second edition of the Core Competencies for Health Care Ethics Consultation report of the American Society for Bioethics and Humanities. The core knowledge and skills competencies identified in the first edition of Core Competencies have been adopted by various ethics consultation services and education programs, providing evidence of their endorsement as health care ethics consultation (HCEC) (...) standards. This revised report was prompted by thinking in the field that has evolved since the original report. Patients, family members, and health care providers who encounter ethical questions or concerns that ethics consultants could help address deserve access to efficient, effective, and accountable HCEC services. All individuals providing such services should be held to the standards of competence and quality described in the revised report. (shrink)

People seeking asylum are at risk of receiving poorer quality healthcare due, in part, to racist and discriminatory attitudes, behaviours and policies in the health system. Despite fleeing war and conflict; exposure to torture and traumatic events and living with uncertainty; people seeking asylum are at high‐risk of experiencing long‐term poor physical and mental health outcomes in their host country. This article aims to raise awareness and bring attention to some common issues people seeking asylum face when seeking (...) healthcare in high‐income countries where the health system is dominated by a Western biomedical view of health. Clinical case scenarios are used to highlight instances of racist healthcare policies and practices that create and maintain ongoing health disparities; limited access to culturally and linguistically appropriate health services, and lack of trauma‐informed approaches to care. Nurses and midwives can play an important role in countering racism in healthcare settings; by identifying and calling out discriminatory practice and modelling tolerance, respect and empathy in daily practice. We present recommendations for individuals, organisations and governments that can inform changes to policies and practices that will reduce racism and improve health equity for people seeking asylum. (shrink)

Medical academics are increasingly bringing critical race theory (CRT) or its corollaries to their discourse, to their curricula, and to their analyses of health and medical treatment disparities. The author argues that this is an error. The author considers the history of CRT, its claims, and its current presence in the medical literature. He contends that CRT is inimical to usual academic modes of inquiry and has obscured rather than aided the analysis of social and medical treatment disparities. Remedies (...) for racism suggested by CRT advocates will not work and some of them will make things worse. Academic medicine should avoid the embrace of CRT and should maintain an allegiance to rigorous empirical inquiry and to treating patients not as essentialized ethnic group members but as individual human beings in need of care. (shrink)

Poor health is not inherently a part of Black Americans’ bodies; poor health is not in our DNA. But as Linda Villarosa says in Under the Skin “something about being Black has led to the documented poor health of Black Americans.”1 Like many other scholars of Black health have said, Villarosa proposes, and evidence supports, that “the something is racism.”2 Villarosa attributes Black people’s generally inferior health outcomes in areas like pregnancy and birth, pain (...) care, and cardiology to racism and not a lack of social resources such as money, education, and access to healthcare. Although not always explicitly stated in her text, the stories Villarosa uses to illustrate racism’s effects on health also demonstrate racism’s influence on who has access to the social resources that are needed to maintain health and treat illnesses. Villarosa is right that more education and more income cannot de facto give Black people better health. At the same time, we cannot ignore that although racism is the force, education, money, housing, and access to healthcare are the means by which racism adversely affects health. Education and other social goods only fail to confer better health to Black people because racism serves as a roadblock. (shrink)

Inequitable access to health care, social inequities, and racist and discriminatory care has resulted in the trend toward poorer health outcomes for Indigenous infants and their families when compared to non‐Indigenous families in Canada. How Indigenous mothers experience care during an admission of their infant to the Neonatal Intensive Care Unit has implications for future health‐seeking behaviors which may influence infant health outcomes. Nurses are well positioned to promote positive health (...) class='Hi'>care interactions and improve health outcomes by effectively meeting the needs of Indigenous families. This qualitative study was guided by interpretive description and the Two‐Eyed Seeing framework and aimed to understand how Indigenous mothers experience accessing and using the health care system for their infants. Data were collected by way of interviews and a discussion group with self‐identifying Indigenous mothers of infants less than two years of age living in Hamilton, Ontario, Canada. Data underwent thematic analysis, identifying nursing strategies to support positive health care interactions and promote the health and wellness of Indigenous infants and their families. Building relationships, providing holistic care, and taking a trauma‐informed approach to the involvement of child protection services are three key strategies that nurses can use to positively impact health care experiences for Indigenous families. (shrink)

A frenetic search for equality lies at the center of much secular and even “Christian” bioethics. In a secular world, if one does not believe in God, if this life is one's whole existence, it would seem that one could not settle for less than equal approbation, especially equality before the risks of suffering and death, which medicine promises to ameliorate. Yet, the concern for equality in health care is puzzling. After a modest level of access to (...) class='Hi'>health care there is little difference in average life expectancy. Are concerns for equality in health care even vaguely Christian? The pursuit of Christian perfection has never been correctly equated with state-imposed egalitarianism. Furthermore, an all-encompassing, secular, egalitarian health care system may provide equal access to significantly immoral medical treatments. In contrast to secular thought, the call of Christianity is a call to holiness, not a call to an egalitarianism that superficially resonates with certain elements of Christian thought. (shrink)

In this paper a case is used to demonstrate how ethical analysis enables health care professionals, patients and family members to make treatment decisions which ensure that medical technologies are used in the overall best interests of the patient. The claim is made and defended that ethical analysis can secure four beneficial outcomes when medical technologies are employed: (1) not allowing any medical technologies to be employed until the appropriate decision makers are identified and consulted; (2) insisting that (...) medical technologies be employed not merely to promote the medical interests of the patient but rather on the basis of their ability to contribute to the overall well-being of the patient; (3) challenging caregivers to reflect on the dynamic interplay between their conscious and unconscious values and consequent determinations of what is in the patient's best interests; and (4) providing a justification for selected interventions which makes possible rational dialogue between caregivers espousing different viewpoints about treatment options. (shrink)

Patients who are subject to compulsory care constitute a substantial proportion of the work-load of mental health professionals, particularly psychiatric nurses. This article examines the traditional ‘beneficence-autonomy’ approach to ethics in compulsory psychiatric care and evaluates it against the reality of daily practice. Risk to the public has always been an important but often unacknowledged consideration. Inequalities exist among ethnic and socio-economic groups and there is a lack of agreement on what constitutes mental disorder. Two major changes (...) in compulsory psychiatric care - community orders and care for patients with untreatable severe personality disorders - further challenge the traditional ethical approach. There are also important human rights implications. The simple patient-health professional relationship no longer provides an adequate framework for mental health professionals on which to base their ethical decisions. The public and organizations may have different perspectives and their interests are becoming increasingly important. Mental health professionals, particularly psychiatric nurses, may face ethical dilemmas because of these different perspectives. (shrink)

Ford, Norman Catholic healthcare facilities fulfil their mission in the world of the sick and dying of all ages. Challenges occasionally arise to remain faithful to their identity and mission in a world whose ethical standards are changing. This article discusses the nature of the challenges ahead.

Reviews the basic Catholic moral principles that apply to health care, then uses them to assess three major current trends in the health care industry.

Health care organization foundations and other fund-raising departments often function at an arm’s length from the system at large. As such, operations related to their mandate to raise funds and market the organization do not receive the same level of ethical scrutiny brought to bear on other arms within the organization. An area that could benefit from a more focused ethics lens is the use of language and rhetoric employed in order to raise funds and market the organization. (...) Such departments and divisions often utilize overblown promises of miracles and extraordinary advances to convince donors to contribute and to persuade the general public. The result can be a heightened sense of expectation on the part of patients, their families, and the general public as to what can realistically be achieved by the health care system, leading to disappointment and conflict when these expectations are not or cannot be met. This article suggests that such advertising and marketing be subject to the same advertising standards as other businesses. (shrink)

Medical ethics should show how an adequate description of morality is helpful in dealing with the problems that arise in the context of medical care. However none of the standard moral theories provide such a description. Further, all of these theories assume that there must be a unique correct answer to every moral question, though this answer may be that it is indifferent which of the proposed solutions one picks. The failure to recognize that there are unresolvable moral disagreements (...) leads many philosophers to think that their moral theories will enable them to determine which policies ought to be adopted. However, the correct role for moral theories is more limited: to rule out morally unacceptable policies. Moral theories almost never can settle disputes about which of two well supported health care policies ought to be adopted. (shrink)

When the President’s Commission of 1983 concluded that there is an “ethical obligation” to secure universal access to a decent minimum of health care, some hoped that this standard would be achieved in the United States within a few years. Nearly 30 years later, when we began work on this issue of the Journal of Medicine and Philosophy (JMP), that standard had yet to be achieved, although the bills that would later become the Affordable Care Act (ACA) (...) were then working their way through Congress. Now, the ACA has been passed and signed into law. The provisions of that bill aim at achieving universal access to an “essential health benefits (EHBs) package". (shrink)

The opportunity and ability to enjoy a health life is, indisputably, a basic human right. As a consequence, governments are responsible for delivering health care to all. Within this framework, physicians must assume the ethical responsibility for doing their utmost to achieve this goal.

In recent months, Covid‐19 has devastated African American communities across the nation, and a Minneapolis police officer murdered George Floyd. The agents of death may be novel, but the phenomena of long‐standing epidemics of premature black death and of police violence are not. This essay argues that racial health and health care disparities, rooted as they are in systemic injustice, ought to carry far more weight in clinical ethics than they generally do. In particular, this essay examines (...) palliative and end‐of‐life care for African Americans, highlighting the ways in which American medicine, like American society, has breached trust. In the experience of many African American patients struggling against terminal illness, health care providers have denied them a say in their own medical decision‐making. In the midst of the Covid‐19 pandemic, African Americans have once again been denied a say with regard to the rationing of scarce medical resources such as ventilators, in that dominant and ostensibly race‐neutral algorithms sacrifice black lives. Is there such thing as a “good” or “dignified” death when African Americans are dying not merely of Covid‐19 but of structural racism? (shrink)

A dominant cultural narrative within Costa Rica describes Costa Ricans not only as different from their Central American neighbours, but it also exalts them as better: specifically, as more white, peaceful, egalitarian and democratic. This notion of Costa Rican exceptionalism played a key role in the creation of their health care system, which is based on the four core principles of equity, universality, solidarity and obligation. While the political justification and design of the current health care (...) system does, in part, realize this ideal, we argue that the narrative of Costa Rican exceptionalism prevents the full actualization of these principles by marginalizing and excluding disadvantaged groups, especially indigenous and black citizens and the substantial Nicaraguan minority. We offer three suggestions to mitigate the self-undermining effects of the dominant national narrative: 1) encouragement and development of counternarratives; 2) support of an emerging field of Costa Rican bioethics; and 3) decoupling health and national successes. (shrink)

Effectiveness, efficiency and equity in health care are discussed in this article against the background of concerns that cost containment may lead to reductions in quality of care. It is suggested that effectiveness is best seen from the patient's point of view and that it relates to more than simply improved health status. Efficiency and equity are better viewed from a societal stance.The paper discusses the role of the medical profession in effectiveness, efficiency and equity and (...) argues that the role of medical doctors needs to be constrained. (shrink)

Although not legally established, the idea that every American has a right to some level of health care has gained wide acceptance. Support for this right has developed primarily in the 50 years since the end of World War II. No mention of health care can be found in either the Declaration of Independence or the Constitution; indeed, there was little anyone could to improve health care or health outcomes in colonial times. During (...) the 19th and early 20th centuries a government role in improving public health developed when certain services, such as clean water, or certain demands upon its citizens, such as quarantine for disease, were instituted in order to achieve better and safer conditions for the health of the general populace. (shrink)

This paper takes up the question of the role of philosophical moral theory in our attempts to resolve the ethical problems that arise in health care, with particular reference to the contention that we need theory to be determinative of our choice of actions. Moral theorizing is distinguished from moral theories and the prospects for determinacy from the latter are examined through a consideration of the most promising candidates: utilitarianism, deontology and the procedures involved in reflective equilibrium. It (...) is argued that the current lack of any generally accepted method of solving moral problems, together with the extreme improbability of philosophy achieving a plausibly determinate theory, should encourage us to approach the problems in a spirit of agnosticism regarding the way in which theoretical material might be of relevance. The practical test for both moral theorizing and moral theories is thus not determinacy but the degree to which they increase our understanding of moral problems by serving, as they do in philosophy, as a means of inquiry into their nature. (shrink)

IntroductionThere is a significant disparity in the United States between the health care received by children with special health care needs versus physically healthy children.ObjectiveThe objective of the paper is to show that children with special needs receive less than adequate health care overall. This disparity affects the quality of life for these children and influences their ability to live their lives to their full potential.MethodsResearch was conducted by examining multiple studies with a focus (...) on six major factors that play a role in creating this disparity.ResultsThe findings show an alarming trend in the access and delivery of health care to children with special health care needs.ConclusionsSolutions to correcting the disparities are possible, but it will take a full understanding of the issues, perseverance, dedication, and hard work on the part of families, physicians, legislators, and others genuinely interested in creating an equal health care system for all children. (shrink)

Book reviewed in this article: Long Term Care: Principles, Programs and Policies. By Rosalie A. Kane and Robert L. Kane. Long Term Health Care: providing a Spectrum of Services to the Aged. By Philip W. Brickner, Anthony J. Lechich, Roberta Lipsman, and Linda K. scharer.

Through an analysis of several high‐profile scandals in health‐care in the UK, this article discusses the nature of scandal and its impact on policy reform. The nursing profession is compared to social work and medicine, which have also undergone considerable examination and change as a result of scandals. The author draws on reports from public inquiries from 1945 to 2013 to form the basis of the discussion about policy responses following scandals in health‐care. In each case, (...) the nature of the scandal, the public and government discourses generated by events and the policy response to those failings are explored. These scandals are compared to the recent scandal at Mid Staffordshire Hospital. Conclusions are drawn about the impact of these events on the future of the profession and on health policy directions. Recent events have raised public anxieties about caring practices in nursing. Health policy reform driven by scandal may obscure the effect of under resourcing in health services and poses a very real threat to the continued support for state‐run services. Understanding the socially constructed nature of scandal enables the nurse to develop a greater critical awareness of policy contexts in order that they can influence health service reform. (shrink)

Health justice seeks, both conceptually and in practice, to strengthen community engagement and empowerment as an integral means of addressing health disparities. In this essay, we explore the nature of communities and their roles in health care/public health. We propose that an ethical principle of respect for communities is a requisite part of health justice. It is this respect for communities that ethically grounds health justice’s calls for greater community engagement and empowerment. Conceptions (...) of health justice, we claim, will gain ethical power and coherence as this principle is more clearly recognized and further developed. (shrink)

The problem of providing mandated medical care has become commonplace as correctional systems in the United States struggle to manage unprecedented increases in its aging prison population. This study explores older incarcerated women’s perceptions of prison health care policies and their day-to-day survival experiences. Aggregate data obtained from a sample of 327 older women residing in prison facilities in five Southern states were used to identify a baseline of health conditions and needs for this vulnerable group. (...) With an average of 4.2 chronic health conditions, frequently histories of victimization, and high rates of mental health issues, the women’s experiences of negotiating health care was particularly challenging. By incorporating the voices of older women, we expose the contradictions, dilemmas, and obstacles they experience in their attempts to obtain health care. It is clear from the personal accounts shared that, despite court mandates, penal harm practices such as delaying or denying medical treatment as well as occasional staff indifferences are common in women’s prisons. With older women having the greatest need for health care, an age- and gender-sensitive approach is recommended. (shrink)