Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Ethnicity. Show all posts
Showing posts with label Ethnicity. Show all posts

Tuesday, January 31, 2023

Why VIP Services Are Ethically Indefensible in Health Care

Denisse Rojas Marquez and Hazel Lever
AMA J Ethics. 2023;25(1):E66-71.
doi: 10.1001/amajethics.2023.66.

Abstract

Many health care centers make so-called VIP services available to “very important persons” who have the ability to pay. This article discusses common services (eg, concierge primary care, boutique hotel-style hospital stays) offered to VIPs in health care centers and interrogates “trickle down” economic effects, including the exacerbation of inequity in access to health services and the maldistribution of resources in vulnerable communities. This article also illuminates how VIP care contributes to multitiered health service delivery streams that constitute de facto racial segregation and influence clinicians’ conceptions of what patients deserve from them in health care settings.

Insurance and Influence

It is common practice for health care centers to make “very important person” (VIP) services available to patients because of their status, wealth, or influence. Some delivery models justify the practice of VIP health care as a means to help offset the cost of less profitable sectors of care, which often involve patients who have low income, are uninsured, and are from historically marginalized communities.1 In this article, we explore the justification of VIP health care as helping finance services for patients with low income and consider if this “trickle down” rationale is valid and whether it should be regarded as acceptable. We then discuss clinicians’ ethical responsibilities when taking part in this system of care.

We use the term VIP health care to refer to services that exceed those offered or available to a general patient population through typical health insurance. These services can include concierge primary care (also called boutique or retainer-based medicine) available to those who pay out of pocket, stays on exclusive hospital floors with luxury accommodations, or other premium-level health care services.1 Take the example of a patient who receives treatment on the “VIP floor” of a hospital, where she receives a private room, chef-prepared food, and attending physician-only services. In the outpatient setting, the hallmarks of VIP service are short waiting times, prompt referrals, and round-the-clock staffing.

While this model of “paying for more” is well accepted in other industries, health care is a unique commodity, with different distributional consequences than markets for other goods (eg, accessing it can be a matter of life or death and it is deemed a human right under the Alma-Ata Declaration2). The existence of VIP health care creates several dilemmas: (1) the reinforcement of existing social inequities, particularly racism and classism, through unequal tiers of care; (2) the maldistribution of resources in a resource-limited setting; (3) the fallacy of financing care of the underserved with care of the overserved in a profit-motivated system.

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Conclusion

VIP health care, while potentially more profitable than traditional health care delivery, has not been shown to produce better health outcomes and may distribute resources away from patients with low incomes and patients of color. A system in which wealthy patients are perceived to be the financial engine for the care of patients with low incomes can fuel distorted ideas of who deserves care, who will provide care, and how expeditiously care will be provided. To allow VIP health care to exist condones the notion that some people—namely, wealthy White people—deserve more care sooner and that their well-being matters more. When health institutions allow VIP care to flourish, they go against the ideal of providing equitable care to all, a value often named in organizational mission statements.22 At a time when pervasive distrust in the medical system has fueled negative consequences for communities of color, it is our responsibility as practitioners to restore and build trust with the most vulnerable in our health care system. When evaluating how VIP care fits into our health care system, we should let health equity be a moral compass for creating a more ethical system.

Friday, October 28, 2022

Gender and ethnicity bias in medicine: a text analysis of 1.8 million critical care records

David M Markowitz
PNAS Nexus, Volume 1, Issue 4,
September 2022, pg157

Abstract

Gender and ethnicity biases are pervasive across many societal domains including politics, employment, and medicine. Such biases will facilitate inequalities until they are revealed and mitigated at scale. To this end, over 1.8 million caregiver notes (502 million words) from a large US hospital were evaluated with natural language processing techniques in search of gender and ethnicity bias indicators. Consistent with nonlinguistic evidence of bias in medicine, physicians focused more on the emotions of women compared to men and focused more on the scientific and bodily diagnoses of men compared to women. Content patterns were relatively consistent across genders. Physicians also attended to fewer emotions for Black/African and Asian patients compared to White patients, and physicians demonstrated the greatest need to work through diagnoses for Black/African women compared to other patients. Content disparities were clearer across ethnicities, as physicians focused less on the pain of Black/African and Asian patients compared to White patients in their critical care notes. This research provides evidence of gender and ethnicity biases in medicine as communicated by physicians in the field and requires the critical examination of institutions that perpetuate bias in social systems.

Significance Statement

Bias manifests in many social systems, including education, policing, and politics. Gender and ethnicity biases are also common in medicine, though empirical investigations are often limited to small-scale, qualitative work that fails to leverage data from actual patient–physician records. The current research evaluated over 1.8 million caregiver notes and observed patterns of gender and ethnicity bias in language. In these notes, physicians focused more on the emotions of women compared to men, and physicians focused less on the emotions of Black/African patients compared to White patients. These patterns are consistent with other work investigating bias in medicine, though this study is among the first to document such disparities at the language level and at a massive scale.

From the Discussion Section

This evidence is important because it establishes a link between communication patterns and bias that is often unobserved or underexamined in medicine. Bias in medicine has been predominantly revealed through procedural differences among ethnic groups, how patients of different ethnicities perceive their medical treatment, and structures that are barriers-to-entry for women and ethnic minorities. The current work revealed that the language found in everyday caregiver notes reflects disparities and indications of bias—new pathways that can complement other approaches to signal physicians who treat patients inequitably. Caregiver notes, based on their private nature, are akin to medical diaries for physicians as they attend to patients, logging the thoughts, feelings, and diagnoses of medical professionals. Caregivers have the herculean task of tending to those in need, though the current evidence suggests bias and language-based disparities are a part of this system. 

Thursday, January 9, 2020

How implicit bias harms patient care

Jeff Bendix
medicaleconomics.com
Originally posted 25 Nov 19

Here is an excerpt:

While many people have difficulty acknowledging that their actions are influenced by unconscious biases, the concept is particularly troubling for doctors, who have been trained to view—and treat—patients equally, and the vast majority of whom sincerely believe that they do.

“Doctors have been molded throughout medical school and all our training to be non-prejudiced when it comes to treating patients,” says James Allen, MD, a pulmonologist and medical director of University Hospital East, part of Ohio State University’s Wexner Medical Center. “It’s not only asked of us, it’s demanded of us, so many physicians would like to think they have no biases. But it’s not true. All human beings have biases.”

“Among physicians, there’s a stigma attached to any suggestion of racial bias,” adds Penner. “And were a person to be identified that way, there could be very severe consequences in terms of their career prospects or even maintaining their license.”

Ironically, as Penner and others point out, the conditions under which most doctors practice today—high levels of stress, frequent distractions, and brief visits that allow little time to get to know patients--are the ones most likely to heighten their vulnerability to unintentional biases.

“A doctor under time pressure from a backlog of overdue charting and whatever else they’re dealing with will have a harder time treating all patients with the same level of empathy and concern,” van Ryn says.

The info is here.

Monday, February 26, 2018

How Doctors Deal With Racist Patients

Sumathi Reddy
The Wall Street Journal
Originally published January 22, 2018

Her is an excerpt:

Patient discrimination against physicians and other health-care providers is an oft-ignored topic in a high-stress job where care always comes first. Experts say patients request another physician based on race, religion, gender, age and sexual orientation.

No government entity keeps track of such incidents. Neither do most hospitals. But more trainees and physicians are coming forward with stories and more hospitals and academic institutions are trying to address the issue with new guidelines and policies.

The examples span race and religion. A Korean-American doctor’s tweet about white nationalists refusing treatment in the emergency room went viral in August.

A trauma surgeon at a hospital in Charlotte, N.C., published a piece on KevinMD, a website for physicians, last year detailing his own experiences with discrimination given his Middle Eastern heritage.

Penn State College of Medicine adopted language into its patient rights policy in May that says patient requests for providers based on gender, race, ethnicity or sexual orientation won’t be honored. It adds that some requests based on gender will be evaluated on a case-by-case basis.

The article is here.

Wednesday, October 25, 2017

Cultivating Humility and Diagnostic Openness in Clinical Judgment

John R. Stone
AMA Journal of Ethics. October 2017, Volume 19, Number 10: 970-977.

Abstract
In this case, a physician rejects a patient’s concerns that tainted water is harming the patient and her community. Stereotypes and biases regarding socioeconomic class and race/ethnicity, constraining diagnostic frameworks, and fixed first impressions could skew the physician’s judgment. This paper narratively illustrates how cultivating humility could help the physician truly hear the patient’s suggestions. The discussion builds on the multifaceted concept of cultural humility as a lifelong journey that addresses not only stereotypes and biases but also power inequalities and community inequities. Insurgent multiculturalism is a complementary concept. Through epistemic humility—which includes both intellectual and emotional components—and admitting uncertainty, physicians can enhance patients’ and families’ epistemic authority and health agency.

The article is here.

Tuesday, October 25, 2011

Would You Like to See a Christian Psychologist?

By Sam Knapp, Ed.D., ABPP
Director of Professional Affairs

Some patients will request a psychologist of a particular gender, and psychologists will usually try to accommodate those concerns. For example, a female patient with sensitive sexual or gender-related issues might not feel comfortable raising them with a male psychologist, and an effort will be made to find a woman psychologist. However, is it possible to implicitly accept or endorse discriminatory practices by agreeing to other similar requests? For example, should psychologists respect the preferences of prospective patients who want to have Christian psychologists?

Some conservative Christians fear that psychologists will mock their religious beliefs or try to blame their problems on their religion. Consequently, having a Christian psychologist may be very important for them. Most non-Christian psychologists I have spoken to have received phone calls from prospective patients who ask them if they are Christian. One psychologist commonly responds, “no, but I am very respectful of Christian beliefs and will help you formulate goals consistent with your beliefs.” So far, no prospective Christian patient has ever failed to make an appointment after that conversation.

How should a psychologist respond if asked to provide a referral for a Christian psychologist? Perhaps one response would be to anticipate the concern of the patients, which is to have someone who respects their beliefs, without necessarily restricting the referrals to a psychologist who happens to be a Christian. It could be possible to respond by saying, “Psychologists are expected to respect the religious beliefs of their patients. I don’t have a list of Christian psychologists, but here are psychologists whom I know to be respectful of Christian beliefs.”

Should race, ethnicity, or sexual orientation be a factor in making a referral? On the one hand, it seems reasonable that some patients may want assurance that the psychologist they have will understand their racial or cultural background or respect their sexual orientation. It is possible to imagine a prospective patient who has not had a history of positive experiences with European Americans, or who has had a background with issues or struggles that even a sensitive European American would have difficulty understanding. Or, consider the case of a European American family who adopted an African American child who generally did well in school and at home. However, as a teenager he struggled to consolidate his racial identity and asked to speak to an African American psychologist.  It appears that race would be a relevant factor in making that referral.

On the other hand, psychologists who defer to patient preferences for race may inadvertently reinforce racist attitudes. So, the perception of the clinical relevance of the request appears important. Psychologists can decide how to respond to these requests by looking to three overarching ethical principles. First, we generally want to respect patient autonomy, including respecting their preferences in a health care professional. Second, we typically want to give patients a referral based on beneficence and nonmaleficence; that is, we want to provide a referral based on who we think can help the prospective patient. Finally, we are also guided by the overarching ethical principle of justice wherein we refuse to engage in unfair discrimination based on race, religion, gender, national origin, or other factors. Often justice is sufficiently important to trump other ethical principles.

I once had a patient who wanted a referral to a different psychiatrist because he said the one I had sent him to was not a “real American” (the psychiatrist was an American citizen of Filipino descent and highly competent). I refused to give him a new referral, and he stayed with the Filipino American psychiatrist, who was of benefit to him. In this case, the overarching ethical principle of justice trumped the other ethical principles. However, I might have responded differently if this patient were highly suicidal or homicidal. Then I would have made inquiries about his concerns, but ultimately deferred to his wish if doing so substantially reduced the risk of death.

Please feel free to contact me with your thoughts on this issue.