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Health Disparities, Ethics, and the Elderly: Theory to Practice
John R. Stone, MD, PhD April 2010
Center for Health Policy and Ethics, Creighton University Medical Center, 2500 California Plaza, Omaha, NE [email protected] , http://chpe.creighton.edu/people/profiles/stone.htm
Learning Objectives
Describe relations of ethics and interactive social influences on health.
Explain what social justice demands in addressing health.
Explain practical implications of ethics for addressing elderly health disparities in Deep South RCMAR.
Maternal
Maternal
Paternal
Causality, Capability, Ethics
Ecological causality/social determinants
Equality of capability Respect, social justice, care, solidarity
Ecological Causality & Health
Geiger 2006
SE: SocioeconomicENV: EnvironmentH: HistoryED: EducationSS: Social statusG: GeographyCH: Childhood
Justice
Sen, Amartya. The Idea of Justice. Harvard Univ. Press, 2009
Equality of capability
A primary objective of social justice should be to provide everyone with the means of and opportunity for equality of capability.
Capability: What people can actually do and be.
Sen 2009
Social Justice & Public Health
Powers, Madison; Faden, Ruth. Social Justice: The Moral Foundations of Public Health and Health Policy. New York: Oxford Univ. Press, 2006.
Dimensions of Well-being
Health Personal security Reasoning Respect Attachment Self-determination
Sufficient
Powers & Faden 2006
Dimensions of Well-being
Powers & Faden (Dimensions)
Research
Policy
Intervention
Collaboration & Partnering
Interactions & Ethics
Well-being Dimensions•Health•Personal security•Reasoning•Respect•Attachment•Self-determination
Social Determinants of Health•Income/wealth•Physical environment•Social environment•Healthcare acc/qual•Historical narratives
Powers & Faden (Dimensions)
Research
Policy
Intervention
Ethics
Policy, Social Justice, Environment, Individual Behavior
“Health promotion interventions take place in a complex environment that includes family and social relationships, economic and geographic factors, and physical barriers and opportunities, all of which influence older persons’ ability to process health information and translate it into new behavior.”
NRC 2004, p.115
Aging & Well-being
“There is increasing evidence that well-being in advanced age is as much if not more a function of social connection and respect then of access to medical technology.”
Powers & Faden 2006, pp. 164-5
Social Justice & Public Health
Remediate “systematic disadvantage” that reduces length and health-related quality of life› Identify› Prioritize responses› Act› Avoid/change policy that disadvantage
Powers & Faden 2006, pp 87,99
Ethical Foundations - 1
Ethical Foundations - 2
Ethical Foundations - 3
Health, Race/Ethnicity (R/E), and Age: Research Needs
Healthcare institutions: Quality assessments by R/E that are sorted by age
Local services: Assessments of access and services by R/E that are correlated with age
Ethical Scope & Ecological Causality
Policy advocacy and drafting Collaborative community partnerships
› CBPR› Translation/intervention
Inter-/trans-disciplinary Institutional (structural/cultural criticism) Multiculturalism (including race, ethnicity,
“culture,” language): cuts vertically (historically) & horizontally (now)
Causality & Disciplines
“There is no settled and accepted set of principles for addressing causal questions within the social sciences and different disciplines have different levels of tolerance for various kinds of assumptions.” (IOM 37)› What decision processes?› How do cultural issues influence process
and outcomes?
Ethical Need
Ethics of collaboration & partnering› Community, academy, agencies, other orgs
Research Intervention Policy
› Among disciplines› Discipline groups and communities
Some resources: Baldwin et al. 2009, Israel et al. 1998, Stone & Dula 2008, Wallwork 2008
Ethics, Agendas, Disparities
Easier: enhancing screening Harder: socioeconomic issues
Partridge & Fouad 2010
Ethics, Elderly, Health Disparities
Should a special ethics be developed?› Representation› Intergenerational trauma› Intergenerational cultural differences› Communication› Advocacy› Concept of analysis
Ethics & Critical approach
Postmodern, postcolonial, critical theory
Assume hidden means of domination, power, marginalization
Attitudes Structures (institutional, processes) Language Grant proposal design Biomedical & public health models Community and state services or agencies
Ethics & Elderly Health Disparities
Collaboration/partnering & community Special issues
› Chronic care› Chronic disease/debility› Continuity & coordination› Transportation › Advocacy › Navigators, helpers, age-bridgers› Abuse› Life-course traumas› Relationships/connectedness
Ethics & Elderly Health Disparities
Attributes/knowledge/attitudes History/narratives
Knowledge Connection Identification
Modes of showing respect Age bias
Ethics & Deep South RCMAR
1. Mentoring2. Workforce diversity3. Older AA recruitment4. Support enduring
research or new directions
5. Better methods/tools6. Increase scientific
knowledge to reduce health disparities
7. Disseminate
1. Collaboration, cultural humility*, deliberation, iteration
2. Advocacy, insurgent multiculturalism**
3. Respect, care, solidarity4. Structural critique & reform5. Insurgent multiculturalism**6. Inclusive collaboration,
community knowledge & priorities
7. Community knowledge & priorities, local/regional needs
*Tervalon & Murray-Garcia 1998**Wear 2003
References
Baldwin JA, Johnson JL, Benally CC. Building partnerships between indigenous communities and universities: Lessons learned in HIV/AIDS and substance abuse prevention research. Am J Public Health. 2009; 99 Suppl 1:S77-82.
Geiger HJ. Health Disparities. What do we know? What do we need to know? What should we do? In: Schulz AJ, Mullings L (eds). Gender, Race, Class, & Health: Intersectional Approaches. San Francisco: Jossey-Bass, 2006:261-288.
Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: Assessing partnership approaches to improve public health. Annu Rev Public Health. 1998; 19:173-202.
NRC: National Research Council. (2004). Understanding Racial and Ethnic Differences in Health in Late Life: A Research Agenda. Panel on Race, Ethnicity, and Health in Later Life. Roldolfo A. Bulatao and Norman B. Anderson, eds. Committee on Population, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies. (Accessed April 27, 2010) http://books.nap.edu/openbook.php?record_id=11036&page=R2
Partridge E, Fouad M. Community-driven approaches for reducing health disparities in cancer. JAMA. 2010; 303(11):1090-1091.
Powers, Madison; Faden, Ruth. Social Justice: The Moral Foundations of Public Health and Health Policy. New York: Oxford Univ. Press, 2006.
References
Powers, Madison; Faden, Ruth. Social Justice: The Moral Foundations of Public Health and Health Policy. New York: Oxford Univ. Press, 2006.
Sen, Amartya. The Idea of Justice. Harvard Univ. Press, 2009. Stone JR and Dula A. “Race/Ethnicity, Trust, and Health
Disparities: Trustworthiness, Ethics, and Action.” In Cultural Proficiency in Addressing Health Disparities. Kosoko-Lasaki S, Cook CT, O'Brien RL. (Eds.) Sudbury, MA: Jones & Bartlett, 2008, pp. 37-56.
Wallwork E. Ethical analysis of research partnerships with communities. Kennedy Inst Ethics J. 2008; 18(1):57-85.
Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multiculural education. J of Health Care for the Poor and Underserved. 1998; 9(2):117-125.
Wear D. Insurgent multiculturalism: Rethinking how and why we teach culture in medical education. Academic Medicine. 2003; 78(6):549-554.