Health Disparities, Ethics, and the Elderly: Theory to Prac - PowerPoint Presentation

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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 68178

johnstone@creighton.edu

,

http://chpe.creighton.edu/people/profiles/stone.htm

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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. Slide3

MaternalSlide4

MaternalSlide5

PaternalSlide6

Causality, Capability, Ethics

Ecological causality/social determinantsEquality of capabilityRespect, social justice, care, solidaritySlide7

Ecological Causality & Health

Geiger 2006

SE: Socioeconomic

ENV: Environment

H: History

ED: Education

SS: Social status

G: Geography

CH: ChildhoodSlide8

Justice

Sen, Amartya. The Idea of Justice. Harvard Univ. Press, 2009Slide9

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

2009Slide10

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.Slide11

Dimensions of Well-being

HealthPersonal securityReasoningRespectAttachment

Self-determination

Sufficient

Powers &

Faden 2006Slide12

Dimensions of Well-being

Powers & Faden (Dimensions)

Research

Policy

Intervention

Collaboration & PartneringSlide13

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

EthicsSlide14

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.115Slide15

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-

5Slide16

Social Justice & Public Health

Remediate “systematic disadvantage” that reduces length and health-related quality of lifeIdentifyPrioritize responses

Act

Avoid/change policy that



disadvantage

Powers

& Faden 2006, pp

87,99Slide17

Ethical Foundations - 1Slide18

Ethical Foundations - 2Slide19

Ethical Foundations - 3Slide20

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 a

ccess and services by R/E that are correlated with ageSlide21

Ethical Scope & Ecological Causality

Policy advocacy and draftingCollaborative community partnershipsCBPRTranslation/intervention

Inter-/trans-disciplinary

Institutional (structural/cultural

criticism)

Multiculturalism (including race, ethnicity, “culture,” language): cuts vertically (historically) & horizontally (now)Slide22

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?Slide23

Ethical Need

Ethics of collaboration & partneringCommunity, academy, agencies, other orgsResearchIntervention

Policy

Among disciplines

Discipline groups and communities

Some resources:

Baldwin et al.

2009, Israel et al. 1998, Stone &

Dula

2008, Wallwork

2008Slide24

Ethics, Agendas, Disparities

Easier: enhancing screeningHarder: socioeconomic issues

Partridge

& Fouad 2010Slide25

Ethics, Elderly, Health Disparities

Should a special ethics be developed?RepresentationIntergenerational traumaIntergenerational cultural differences

Communication

Advocacy

Concept of analysisSlide26

Ethics & Critical approach

Postmodern, postcolonial, critical theoryAssume hidden means of domination, power, marginalizationAttitudesStructures (institutional, processes)

Language

Grant proposal design

Biomedical & public health models

Community and state services or agenciesSlide27

Ethics & Elderly Health Disparities

Collaboration/partnering & communitySpecial issuesChronic careChronic disease/debility

Continuity & coordination

Transportation

Advocacy

Navigators, helpers, age-bridgers

Abuse

Life-course traumas

Relationships/connectedness Slide28

Ethics & Elderly Health Disparities

Attributes/knowledge/attitudesHistory/narrativesKnowledgeConnection

Identification

Modes of showing respect

Age biasSlide29

Ethics & Deep South RCMAR

MentoringWorkforce 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 Slide30

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

. Slide31

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.