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 68178johnstone@creighton.edu , 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.