The Dr. Norman Fost Award for the Best Medical Student Bioethics Essay Contest — sponsored by the School of Medicine and Public Health and its Department of Medical History and Bioethics — invites medical students annually to critically examine an aspect of the field of bioethics that is relevant to their studies.
Winning Entry – Ninth Annual Bioethics Essay Contest
As a medical student at the University of Wisconsin School of Medicine and Public Health (SMPH), Haley Strouf Motley received the 2023 Dr. Norman Fost Award for the Best Medical Student Bioethics Essay. The ninth-annual contest—sponsored by the SMPH and its Department of Medical History and Bioethics—asked students to choose a topic related to the theme of the April 2023 Bioethics Symposium, “Toward an Anti-racist Bioethics.”
Promoting Cultural Competence and Cultural Safety in Medicine
By Haley Strouf Motley
Racism in medicine is a longstanding yet only recently widely recognized public health threat. From special issue publications advancing a dialogue on antiracist initiatives, to American Medical Association (AMA) policies declaring racism as a threat to public health, recent years have seen a concerted push for social justice and health equity.1,2 This attention and effort is warranted, as racial inequities in health outcomes and experiences persist in Wisconsin and across the United States.3–5 In her article “From a reckoning to racial concordance: a strategy to protect Black mothers, children, and infants,” Nia Johnson outlines patient-provider racial concordance as a necessary but not sufficient tool to improve outcomes for Black patients. She outlines benefits of improved health outcomes for Black patients and also acknowledges potential drawbacks, such as shifting the burden of improving health outcomes onto already marginalized and underrepresented providers.6 Here, I expand on Johnson’s proposal for patient-provider racial concordance by situating it as one tool within a long-term strategic framework.
The utility of patient-provider racial concordance can be best understood as part of a longitudinal transition from cultural competence to cultural safety in medicine. Olson and Anderson define cultural competence as providing services “in ways that are as congruent as possible with the culture of the client being served.”7 They go on to define cultural safety as providing services that “stem from and are based in the culture of the individuals seeking the services.” Culturally competent care might occur when the current population of predominantly white providers seek to recognize, understand, and align their care with their Black patients’ identities and lived experiences. Culturally safe care, on the other hand, may be provided by Black providers from Black patients’ own communities. Long-term solutions to racial health inequities must be rooted in cultural safety, as Johnson alludes to when calling for racial concordance. In the meantime, initiatives promoting cultural competence can help bridge this gap, illuminating a path from the current medical system to one that is equitable and socially just.
Cultural safety in health care can be envisioned as a system in which all members of a community receive medically and culturally appropriate care from providers who are members of their own community in community-specific settings that promote comfort and wellness. Achieving this vision will require systems-level reforms across multiple societal sectors. Monetary, institutional, and geographic barriers to careers in healthcare must be removed.
Racialized notions of professionalism must be rethought, unscientific racial stereotypes removed from educational materials, and racialized clinical practices discontinued. The structure of the healthcare system itself must also be reimagined to allow patients greater agency to select providers that best align with their values and identities. Indeed, the identities that are most important to a patient may not be the ones that are most visible to others. This of course is not a comprehensive list, and long-term partnerships between health systems, educational institutions, and communities will be required to devise and implement strategies specific to the unique needs and values of each community.
The large-scale changes required to achieve cultural safety in healthcare are complex and time-intensive. While this doesn’t diminish the need to pursue them, it does necessitate the adoption of other short-term interventions in the meantime. Until cultural safety is achieved, short-term cultural competence interventions can help address health inequities. Current providers should receive regular, evidence-based bias intervention training. Health professions schools should complement their efforts to recruit diverse trainee cohorts with intentional personal and professional mentorship for underrepresented trainees after matriculation. Health systems should actively promote retention and promotion of Black faculty members and adopt zero-tolerance policies for racial discrimination. Patient-provider racial concordance should be pursued within reasonable limits of expertise, workload, and resources. Like any intervention, racial concordance must be implemented thoughtfully, ensuring that it doesn’t exploit underrepresented providers or promote substandard care for certain populations.
Racial concordance is not sufficient to achieve health equity and should not be utilized as a stand-alone solution to address health disparities. Its utility can be appreciated by situating it within a long-term strategic framework, specifically as part of a longitudinal transition from cultural competence to cultural safety. Addressing racial health inequities will take time, collaboration, and conscious effort. Effective use of patient-provider racial concordance as a tool in a culturally competent framework may help achieve its obsolescence in a culturally safe one.
CITATIONS:
- Faith E. Fletcher, Keisha S. Ray, Virginia A. Brown, Patrick T. Smith. A critical moment in bioethics: Reckoning with anti-Black racism through intergenerational dialogue. Hastings Cent Rep. 2022;52(S1):S3-S11.
- Kevin B. O’Reilly. AMA: Racism is a threat to public health. Published online 2020.
- Sara N. Bleich, Mary G. Findling, Logan S. Casey, et al. Discrimination in the United States: experiences of Black Americans. Health Serv Res. 2019;54(S2):1399-1408.
- L. Silvia Munoz-Price, Ann B. Nattinger, Frida Rivera, et al. Racial disparities in incidence and outcomes among patients with COVID-19. JAMA Netw Open. 2020;3(9):e2021892-e2021892.
- Brandon D. Tomlin, Ryan M. McAdams, Jasmine Y. Zapata, Dinushan C. Kaluarachchi. High Black infant mortality in Wisconsin: factors associated with the ongoing racial inequity. J Perinatol. 2021;41(2):212-219.
- Nia Johnson. From a reckoning to racial concordance: a strategy to protect Black mothers, children, and infants. Hastings Cent Rep. 2022;52(S1):S32-S34.
- S Olson, K. M. Anderson. Leveraging culture to address health inequalities: examples from Native communities: workshop summary. Published online 2013.
ABOUT THE AUTHOR:
Haley Strouf Motley is in her final year of a combined medical degree and master of public health degree at the University of Wisconsin School of Medicine and Public Health. She grew up in Rice Lake, Wisconsin, and became interested in the field of medicine while studying biological engineering at the Massachusetts Institute of Technology. In her future career, Strouf Motley hopes to specialize in pediatrics with a focus on adolescent medicine, LGBTQ+ health, and gender-affirming care.
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Eighth Annual Bioethics Essay Contest winner
Winning Entry — Eighth Annual Bioethics Essay Contest
As a second-year medical student at the University of Wisconsin School of Medicine and Public Health, Bethany M. Erb received the 2022 Dr. Norman Fost Award for the Best Medical Student Bioethics Essay. This year, the contest invited students to critically examine the ethical values and principles relevant to health disparities.
Inequality or Inequity
The Ethics of Health Outcomes in the United States
by Bethany M. Erb
Just as nucleotides link polarized deoxyribonucleic acid strands, many health inequalities are a nexus between race and socioeconomic status in the United States. The COVID-19 pandemic exposed these inequalities in stark fashion. It is well known that non-white populations experience higher rates of COVID-19-related hospitalization and death compared with non-Hispanic white populations, despite accounting for demographic variables.[i] Health inequalities like those from the pandemic, whose effects are unequally distributed between socially constructed groups, are intrinsic moral problems. Unaddressed, these inequalities will sink deeper into the status quo—new mutations of their causal injustices and biases will arise and maintain their original cause: a national tradition of codified racism.
Before we continue, it is important to clarify what health inequalities are inequities—immoral differences in health outcomes. Not all health inequalities necessitate a call-to-arms. For instance, age-related health differences are not considered unjust. While a thirty-year-old has a relatively lower risk of osteoporosis compared to a seventy-year-old, this health difference is rooted in biology; bone resorption is an unavoidable part of the aging process.[ii] The seventy-year-old has had younger bones and the thirty-year-old will soon have older bones; neither individual is denied access to the other’s health state based on their position in shared social hierarchies.
Health inequities are not rooted in biology but rather the unfair distribution of resources and opportunities in the past or present. As such, health inequalities become inequities when it can be shown they are not biologically determined, or simply products of cultural differences, but arise in part due to identity-based discrimination. These inequalities are remnants of institutional oppression, perpetuating unjust economic and social policies born by innocent individuals.
We know that race and socioeconomic status often have a synergistic effect on patterns of disease distribution.[iii] It is increasingly obvious that minority groups face implicit bias within the American healthcare system that affects method and means of treatment and prognosis.[iv],[v] It is well documented that these same groups have historically been denied access to economic and social resources and opportunities that predict positive health outcomes and social stratum.[vi] Since bias towards persons of color is a driving cause of these phenomena, and one of our nation’s moral tenets is that racism is an injustice, a violation of the categorial imperative and norms of equal opportunity and respect, we arrive at a logical finish-line: health inequalities between racial and socioeconomic groups are intrinsic moral problems.
A familiar objection is that health inequalities reflect individual autonomy more than circumstance. If less healthy people are responsible for their health, capable of freely choosing between outcomes, then they are not victims of conditions; rather, they create their fate despite these conditions. If people can make choices in relative isolation from a broader social environment, the individual is the only meaningful level of moral analysis. Health inequalities cannot be injustices if the individual is the sole moral agent responsible for their existence.
I would argue this objection overlooks the neuroscience of free will and the reality of health determinants that lie outside of choice. Current research suggests the unconscious initiates activity, implying a reservoir of feelings, thoughts, urges, and memories spurs action.[vii],[viii] This suggests the social and environmental habitat that helps creates this reservoir is responsible in part for population outcomes. Health inequalities are then moral issues to the degree they reflect injustice grown within this habitat.
It is not necessary to accept this degree of determinism to acknowledge many health predictors defy choice. Poverty, with its physical and psychological stressors and lack of ways to handle these stressors, is one such variable. Simply being born into a low-income family or neighborhood predicts premature mortality and morbidity.[ix] Given historic housing segregation practices and environmental injustices define many low-income areas, it is highly problematic to claim the individual alone can be held responsible for health outcomes shaped by poverty. This example helps us imagine how policy and social determinants of health can be just as, if not more than, responsible as the individual for multifactorial health conditions.[x]
Many health inequalities today are remnants of legislated economic and racial oppression in the United States. These inequalities count as inequities because they maintain codified discrimination between social groups that violates norms of dignity and respect. Thus, we can say these inequalities are intrinsic moral problems. Acknowledging the moral weight of such health inequalities is necessary. We only begin to lift the load of this injustice from our shoulders when we accept it is real and unfit to bear.
References
[i] Lopez L, Hart LH, Katz MH. Racial and Ethnic Health Disparities Related to COVID-19.
JAMA.2021;325(8):719–720.
[ii] Clarke, Bart (2008-11-01). “Normal Bone Anatomy and Physiology”. Clinical Journal of the American Society of
Nephrology. 3(Suppl 3): S131.
[iii] Williams, David R., et. al. “Understanding associations among race, socioeconomic status, and health: Patterns and
prospects.” Health Psychology. American Psychological Association. vol. 35,4 (2016): 407-11.
[iv] FitzGerald, Chloë, and Samia Hurst. “Implicit bias in healthcare professionals: a systematic review.” BMC medical
ethics vol. 18,1 19. 1 Mar. 2017.
[v] Matthew, D. B. (2015). Just medicine: A cure for racial inequality in American health care. NYU Press.
[vi] Hanks, Angela, et. al. (2022, January 19). Systematic Inequality. Center for American Progress. April 24, 2022.
[vii] Smith, K. Neuroscience vs philosophy: Taking aim at free will. Nature 477, 23–25 (2011).
[viii] Bargh, John A, and Ezequiel Morsella. “The Unconscious Mind.” Perspectives on Psychological Science: A Journal
of the Association for Psychological Science vol. 3,1 (2008): 73-9.
[ix] Minkler M. “Personal responsibility for health? A review of the arguments and the evidence at century’s end.”
Health Educ. Behav. 1999 Feb;26(1):121-40.
[x] Braveman, Paula, and Laura Gottlieb. “The social determinants of health: it’s time to consider the causes of the
causes.” Public Health Reports (Washington, D.C.). vol. 129 Suppl. 2, Suppl. 2 (2014): 19-31.