Transcript Healthcare for African Americans Respect, Equality, Trust

Ethics and Healthcare for
African Americans
John R. Stone, MD, PhD
Center for Health Policy and Ethics
Creighton University Medical Center
[email protected]
http://chpe.creighton.edu/chpe/stone.htm
June 1, 2007
Purpose
 Summarize
important themes and ethical
issues in healthcare of African Americans
 Give some broad practical applications
Driving Issue
 Significant
inequalities in health and
healthcare that adversely affect African
Americans
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.
Special Emphasis
 Trust
and trustworthiness
 Respect
Don’t Touch
 She:
“You don’t 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.
Demanding? Hostile?
 White


“Demanding”
Needs met
 Black


patients
patients
“Hostile”
Needs not met, or less well
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. 2007;297:1224-1232.)
Crucial Intersections-AA Healthcare
Unequal
Healthcare
Unequal
Health
Trust
Trustworthiness
People
Humility
EQUAL
CARE
Justice
Community
Care
Principle
Respect
Harper S, Lynch J, Burris S, Smith GD. Trends in the Black-White Life Expectancy
Gap in the United States, 1983-2003. JAMA. 2007;297:1224-1232. From the
United States Life Tables of the National Center for Health Statistics.
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. 2007;297:1224-1232. From the United States Life
Tables of the National Center for Health Statistics.
B/W Life Expectancy @ Birth
Racial/Ethnic
Healthcare 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?
R/E Healthcare
Ethical 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 30:4.
R/E Healthcare Inequalities
Why 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.
Don’t Touch
 She:
“You don’t 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.
Crucial Intersections
Unequal
Healthcare
Unequal
Health
Trust
Trustworthiness
People
Humility
EQUAL
CARE
Justice
Community
Care
Principle
Respect
African Americans
Health, Healthcare, and Ethics
Focus of Ethics Committees?
Focus of Health Professionals?
Demanding? Hostile?
 White


“Demanding”
Needs met
 Black


patients
patients
“Hostile”
Needs not met, or less well
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
Information & Relationships
White/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. 2002;40(1S): I-27–34.
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.
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. 2006;24(6): 904-9.
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. 2006;166:950-954.
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.”
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
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. 2003;28(4):489-516.
Building Rational Trust
Clinical Interactions







Respect
Honesty
Competency
Transparency
Humanistic caring
Sustained patientphysician 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. 2006;166:950-954.
McKinstry B, Ashcroft RE, Car J. Interventions for improving patients' trust in doctors and groups of
doctors. Cochrane Database Syst Rev. 2006;3: CD004134.
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.
Forms of Address
Separate Cases
 HC

Professional: Good morning Sadie.
Ms. Sadie Robinson is 75 years old
 HC
Professional to family member: Let’s
get you a chair.
 HC Professional to family: “What do you
people think would be best for Mr. Taylor?”
 HC Professional: avoids touching
Respect
Equal, Substantial, Particular
 Names
 Touch
 Recognition
 Regard
 Agency
 Passion
and caring
 Sitting and listening
Real Case

Betty (40, healthcare worker):
 “I went to this doctor [for a pap smear]. I had an
infection…She said, “How many sex partners to
do you have? I said “Gulp” and just looked at
her…She said, “Oh, you don’t know how
many”….I felt like was a little piece of garbage. I
was just…stereotyped: “There was a little black
woman who’s 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.
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. 2006;166:950-954.
Respect
 Quality
attention
 Openness (heart, mind)
 Willingness to be vulnerable
Honor
 Deep/authentic curiosity
– Boundaries
 Grows out of



Mutuality
Connection
Engagement
– Privacy
Sarah Lawrence-Lightfoot. Respect: An Exploration. Cambridge, MA: Perseus 2000,
pp. 217, 224
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?
Respect
Institution
Community
Professionals
Policies &
Practices
Healthcare Inequalities
Cross-cultural education & training
 Widely
advised
 Minimal outcome data
Promoting Institutional Change
 Advocacy


Professionals
Communities
 Law
 Ethics
Committees
Prejudice & Stereotypes: Doctors
Don’t think they are prejudiced
Don’t 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: 361388.
Crucial Intersections
Unequal
Healthcare
Unequal
Health
Trust
Trustworthiness
People
Humility
EQUAL
CARE
Justice
Community
Care
Principle
Respect
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. 2007;297:1224-1232.)
Harper S, Lynch J, Burris S, Smith GD. Trends in the Black-White Life Expectancy Gap in the United States, 19832003. JAMA. 2007;297:1224-1232. 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 30:4.


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. 2002;40(1S): I-27–34.

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. 2006;24(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. 2006;166:950-954.
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.