Inequities and Disparities in Healthcare

Earlier this month I went back to my alma mater to attend a conference on healthcare at Samford University. It was presented by the HEAL Institute (Healthcare, Ethics, & Law) and the conference topic was “Eliminating Health-care Delivery Disparities: An Ethical Quagmire?”

The HEAL Institute was organized as an educational and interdisciplinary effort for addressing ethical issues in decision making and delivery of patient care. Dr. David Satcher, former U.S. Surgeon General , was among the presenters at this year’s conference.

Just and Unjust Disparities

Robert Veatch began the conference with “Healthcare Disparities: Just and Unjust.” He gave a striking example of unjust disparity: a young boy on Medicaid who eventually died from complications due to an abscessed tooth because of inadequate access to the healthcare system. If the system had been more equitable, he could have had the tooth treated at a cost Medicaid of $80. As it was, his Medicaid cost was $250,000 and the result was death. The tragedy was that there was a needless death and unnecessarily high costs due to the fact that the system did not allow for equal access to healthcare. To Veatch, universal access to healthcare is a right that should belong to all citizens.

Examples of justified disparities:

• Rationing of healthcare is logical - we have limited resources and must prioritize how those resources are used.
• People are voluntarily less healthy than they might be. “The goal of maximizing health conflicts with the goal of maximizing well-being.” (Think about what you had for breakfast today, or your choices to exercise or not to exercise).

Smoking is an example that leads to a disparity in healthcare costs and it is a monitorable disparity. Obesity and elevated cholesterol, on the other hand are non-monitorable disparities. If a behavior is monitorable and there is a linear cause-effect on health, there should be a health fee, according to Veatch,  to offset costs rather than to have insurance cover all justifiable disparities.

Dr. Veatch is professor of medical ethics at the Kennedy Institute of Ethics and a professor in the Philosophy Department at Georgetown University. His most recent book is Patient Heal thyself: How the “New” Medicine puts the Patient in Charge.

New Horizons in Healthcare

Gregory Pence, Professor of philosophy at the University of Alabama at Birmingham (UAB) gave an interesting presentation “From Stem Cells to Cloning: Where Are We Now?” Dr. Pence offered some fascinating benchmarks from the field of genetics and stem cell research:

• Japan's Shinya Yamanaka won the Kyoto prize for figuring out how to make any cell into a pluripotent stem cell.
• Tim Townes, a researcher at the University of Alabama at Birmingham, created sickle cell anemia in a mouse and cured it, offering hope for a genetic cue for sickle cell anemia.
• At Atlanta’s Shepherd Center a partially paralyzed Alabama nursing student recently became the first to be infused with a drug made from human embryonic stem cells.

Pence also mentioned that James Wilson cautions stem cell research. His own work resulted in death when he was driven to be first in his field of research.

Panel Discussion about Healthcare for Undocumented Immigrant Workers

Denyse Thornley-Brown, associate professor of internal medicine at UAB and medical director of Davita Birmingham North Dialysis Unit, presented a case of a 23-year-old undocumented immigrant who was diagnosed with end stage renal disease (ESRD). The young man had moved to Alabama at age 13. Treatments for ESRD are either dialysis or kidney transplant.

Dr. Thornley-Brown gave statistics of Alabama’s changing demographics with the growth of the Hispanic population. She also mentioned that the Alabama state legislature has recently passed a reactionary Arizona-styled immigration bill.

Other facts to consider in the case:

• Medicaid is a federally funded and state run program for the poor. 
• Ten states provide Medicaid coverage for undocumented immigrants, Alabama does not.
• Most dialysis clinics in the state are for profit enterprises.

Her questions for the panel discussion were: Should the patient be treated? And if so, who should pay?

The panel discussion addressed, or in some cases simply raised questions about needed course of action:

• Why start treatment when the patient will be unable to follow up with outpatient treatment?
• The U.S. needs a more liberal immigration policy to allow for legal residency.
• What are the ethical obligations of the doctors?
• What are the ethical obligations of the hospital?
• Should life-saving treatment be done by for-profit companies?

In her follow up to the discussion, Dr. Thornly-Brown told the audience what actually happened in the young man’s treatment. He has not been able to get a kidney transplant. He has had at least 29 ER visits, most of which resulted in emergency dialysis.

She also told of three other cases involving undocumented immigrants needing similar treatment, two moved to states providing emergency Medicaid services and one returned to Latin America where he died due to lack of funds for dialysis.

Racial Disparities

In the afternoon, Dr. David Satcher gave his presentation titled, “The Health Impact of Resolving Racial Disparities: An Analysis of Mortality Data.” Satcher is, of course, former U.S. Surgeon General. He is also past director of the Centers for Disease Control, and current director of the Satcher Health Leadership Institute. In addition, Dr. Satcher holds the Pouissaint-Satcher-Cosby Chair in Mental Health at Moorehouse School of Medicine in Atlanta, Georgia.

Satcher enumerated various racial disparities are found in cardiac health, infant mortality, cancer mortality, obesity and diabetes. He mentioned that African Americans do not have a higher incidence of breast cancer, but they do have a higher rate of death from breast cancer. If racial disparities in healthcare were eliminated, in the year 2000, for example, there would have been 83,500 fewer deaths among African Americans.

Satcher warned that our current healthcare system is not sustainable. We must reform healthcare in order to move forward. He pointed out that the U.S. is ranked number 1 in healthcare expenditures yet we are number 42 in health outcomes.

Dr. Satcher talked some about his leaving the family farm in Anniston, Alabama to go to Moorehouse College in Atlanta which was his launching into a medical career. He spoke warmly of his indebtedness to the leadership and guidance of Benjamin Mayes, the president of Moorehouse College. He closed his address with a quote from Dr. Mayes:

“It must be borne in mind that the tragedy of life doesn't lie in not reaching your goal. The tragedy lies in having no goal to reach. It isn't a calamity to die with dreams unfulfilled, but it is a calamity not to dream. It is not a disaster to be unable to capture your ideal, but it is a disaster to have no ideal to capture. It is not a disgrace not to reach the stars, but it is a disgrace to have no stars to reach for.”

Much of the information Dr. Satcher gave a PowerPoint presentation is also included in one he presented in Atlanta which can be seen online here.

End of Life Issues

A final case study presented by HEAL Institute director, Dr. Bruce White, illustrated the sometimes complex means for a healthcare facility to implement substituted judgment in the absence of advance directives. End of life care is certainly an area that summons the need for ethical and compassionate practice. The case study presented highlighted for many of us the need to have an advance directive in place.

This was my third time to enjoy the HEAL conference. In addition to great presentations, there is the opportunity to connect with other healthcare professionals. I attended as a hospital cardiac nurse. During the course of the day, I was able to talk with a physician who is in the field of public health, some hospital chaplains, a university professor, a social worker, and other nurses from different hospitals in the city. It is always good to have the time to reflect on the ethical issues we face in the course of our workday and to hear the perspectives of colleagues from other disciplines.