Health Disparities, Ethics, and the Elderly: Theory to Practice

1. 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 68178 johnstone@creighton.edu , http://chpe.creighton.edu/people/profiles/stone.htm

2. 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.

3. Maternal

4. Maternal

5. Paternal

6. Causality, Capability, Ethics • Ecological causality/social determinants • Equality of capability • Respect, social justice, care, solidarity

7. Ecological Causality & Health SE: Socioeconomic ENV: Environment H: History ED: Education SS: Social status G: Geography CH: Childhood Geiger 2006

8. Justice • Sen, Amartya. The Idea of Justice. Harvard Univ. Press, 2009

9. 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

10. 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.

11. Dimensions of Well-being • Health • Personal security • Reasoning • Respect • Attachment • Self-determination • Sufficient Powers & Faden 2006

12. Dimensions of Well-being Collaboration & Partnering Research Policy Intervention Powers & Faden (Dimensions)

13. Ethics Interactions & Ethics Intervention Research • 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 Policy Powers & Faden (Dimensions)

14. 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

15. 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

16. 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

17. Ethical Foundations - 1

18. Ethical Foundations - 2

19. Ethical Foundations - 3

20. 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

21. 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)

22. 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?

23. 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

24. Ethics, Agendas, Disparities • Easier: enhancing screening • Harder: socioeconomic issues Partridge & Fouad 2010

25. Ethics, Elderly, Health Disparities • Should a special ethics be developed? • Representation • Intergenerational trauma • Intergenerational cultural differences • Communication • Advocacy • Concept of analysis

26. 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

27. 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

28. Ethics & Elderly Health Disparities • Attributes/knowledge/attitudes • History/narratives • Knowledge • Connection • Identification • Modes of showing respect • Age bias

29. Ethics & Deep South RCMAR • Mentoring • Workforce diversity • Older AA recruitment • Support enduring research or new directions • Better methods/tools • Increase scientific knowledge to reduce health disparities • Disseminate • Collaboration, cultural humility*, deliberation, iteration • Advocacy, insurgent multiculturalism** • Respect, care, solidarity • Structural critique & reform • Insurgent multiculturalism** • Inclusive collaboration, community knowledge & priorities • Community knowledge & priorities, local/regional needs *Tervalon & Murray-Garcia 1998 **Wear 2003

30. 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.

31. 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.