Chapter 5: Principles in the Ethical Care of Underserved Patients

OBJECTIVES

INTRODUCTION

Eradicating the disparities in health and health care that exist between rich and poor is medicine’s biggest ethical challenge the world over. Tackling this problem is an issue not only of medical ethics but social justice and raises questions about physician’s social and political responsibilities. The obligation to work toward a more just society and system of health care is not universally acknowledged as a professional responsibility. For example, in the United States, there is no obligation for physicians to care for the underserved beyond stabilization in an emergency department or for prisoners. The health-care system and corporate interests are intertwined, with corporate prosperity often trumping patient benefit. Hospital policies, insurers, the government, as well as reigning societal attitudes toward illness and poverty increasingly influence relationships between practitioners and patients.

As health-care providers and other activists advocate for the societal changes that equity in health requires, they must also assure that the vulnerable patients actually cared for receive high-quality, ethical, and compassionate care. There may be host of complexities to navigate to assure this care. Underserved patients frequently are members of ethnic and cultural groups whose decision-making customs and values may differ from those of people from more privileged backgrounds who often dominate the health-care professions. In addition, underserved patients often have low health literacy and numeracy, less education, or significant behavioral health disorders. Thus, to participate actively in their medical decisions and care, they may need additional assistance to gain sufficient understanding of their medical situation. Mistrust of the health-care system may be a potent, but unacknowledged, force in decision making.

APPROACHING ETHICAL ISSUES

Ethical problems arise when it is difficult to act without compromising one ethical principle for another, or personal, professional, or societal moral standards are in conflict. There are three common types of ethical problems. One, sometimes termed ethical distress, occurs when the provider knows what the right course of action is but cannot act on it. This occurs frequently in the care of the underserved. For example, when lack of resources makes it difficult or impossible to pursue the right course of action, ethical distress is created. Ethical conflicts or dilemmas occur, on the other hand, when a course of action fulfills some moral goods but compromises others. Ethical conflicts may arise when there are competing compelling needs. A final common type of ethical quandary, referred to as a problem in locus of authority, arises not over how to approach a particular issue but in who has the moral authority to make a decision. This ...