GOAL: Introduce key terms and reviews the history of health equity briefly
Read the first 3.5 pages of this article to build a broad overview of health equity, it’s evolution, and pertinent terms that will be discussed in class. The remainder of the article references areas of further reading for interested students.
Justice in healthcare is a substantial part of ethics in medicine, here we will cover some of the distinctive aspects of justice-based concerns and some basic ethics language to help wade through these interesting ethical issues.
Now start to apply what you’ve learned. This reading provides some preliminary perspectives on a case of transplant tourism. This is just one among many forms of distributive justice where we see the ethical tensions in rationing at the bedside.
REVIEW THIS CASE: from Satel and Aronson (2008) “Transplant Tourism: Treating Patients when They Return to the U.S.” American Medical Association Journal of Ethics 10(5):271-277.
Mr. Lawrence, a 50-year-old man with diabetes, is on dialysis for chronic renal failure and on the waiting list for a kidney transplant. Because he is in relatively good health, he is low on the list. His physicians advise him that he could be on the list for up to 3 years and that his health during that time would not be jeopardized, aside from the risks and inconveniences associated with long-term dialysis. Mr. Lawrence is divorced and on bad terms with his ex-wife; he has no children and has contacted his sister and her family to see if any of them could be a living donor. His sister is obese, at risk for diabetes, and is not a suitable donor candidate; no other family members or friends are willing to consider donating a kidney to Mr. Lawrence.
Unable to find a living donor and dismayed at the thought of remaining on dialysis for years, Mr. Lawrence decided to use his financial resources to purchase a kidney and undergo a transplant in China. He spent 2 months in China after the surgery, where he was cared for by a local transplant team that provided postoperative care, including monitoring his renal function and managing his immunosuppressant medications. The surgery occurred without any significant complications, and Mr. Lawrence’s recovery was excellent.
A month after his return to the United States, Mr. Lawrence ran out of the medications that his doctors in China had prescribed, including his immunosuppressants. He knew that failing to take the medication could cause graft rejection, so he made an appointment with Dr. Roberts, a nephrologist at a local academic center who specialized in care of renal transplant patients… Dr. Roberts understood how difficult it was to secure an organ, but didn’t want to be perceived as condoning Mr. Lawrence’s actions.
How would you frame the central ethics question in this case?
What are the key features of the case that would guide an ethically appropriate response from your perspective?
What might make this case challenging from your perspective?
WATCH: When thinking about justice, it is important to explore the perspectives of all stakeholders and consider the systems through which they interact. In the case of transplant tourism, this means knowing where organs can come from as well as who seeks them out. This is a problem of global justice, which means that ALL governments and ALL healthcare systems are implicated in our ethical reasoning. See this short video from BBC News that portrays one family’s experience.
As you watch CONSIDER:
How might information about the international organ trade affect your perspective on this case? Would it change your mind about what to do as Mr. Lawrence’s physician if you knew that Mr. Lawrence’s organ was donated by a family member in China, a person experiencing poverty like the family in the above video, or someone who was incarcerated and did not consent?
How does this video and the above case affect your vision of collective efforts towards social justice?
WATCH: Now that you’ve thought about the case on your own, see the perspectives of some experts from different professional backgrounds.
While the professional and experiential backgrounds of these experts are diverse, they do not represent all the relevant stakeholders in this case. Who else would you want to hear from?
Cases like these can bring up a lot of implicit bias, can you identify some of your own? What about some of the experts in the reading and the video?
What are some of the key ethical resolutions or points that really stuck out to you in this case?
READ: in preparation for the discussion of a different case where injustice appears at the bedside, review this OpEd by Dr. Ofri “The Insulin Wars”. This essay provides a robust perspective regarding what it can feel like to face societal injustices that obstruct one’s ability to provide optimal care.
For further reading (not required)…
There are several impressive documentaries on transplant tourism, here is one from the UK that is slightly older (2004) but provides extensive insight into the perspectives of various stakeholders including patients, families, and transplant surgeons on multiple sides of the debate: The Transplant Trade. There is another newer documentary that investigates China’s illegal organ trade called Human Harvest, which can be accessed through the library here.
GOAL: Define and provide examples of Adverse Childhood Experiences. Review the relationship between various forms of trauma/violence/ACEs and health status or health care outcomes throughout the life course.
This massive prospective study is the original research that described the prevalence of certain “adverse childhood events” in a managed care population and provided evidence for the strong correlation with morbidity and mortality later in life. Please note: A caveat that some language in this original paper (“family dysfunction”) would not be used in the trauma informed care environment that this work ultimately produced.
REFLECT: How does this information change the way you think about chronic diseases such as diabetes? In what way does the study population (white, employed, insured, middle class) affect your reading of this article?
4. DISCUSS: Please respond to the following prompt in the discussion board on Canvas:
In reflecting on the data and concepts presented by Dr. Burke , and by the Felliti and Anda study, please consider a patient you have seen in PCP or tutorial who was or may have been affected by toxic stress or adverse childhood experiences.
How might an understanding of the effect of toxic stress across the lifespan changed your interaction with or your understanding of this patient?
As a medical student, what actions can you personally take as you interact with patients that could contribute to a family’s resilience or reduce the risk of re-traumatization during the medical visit?
GOAL: Describe the proposed pathophysiologic mechanisms of toxic stress’ effect on health across the lifespan and the mediating effect of known resilience factors.
In this Pediatrics article, Shonkoff et al, delve into the science of toxic stress on the developing brain and the moderating effect of resilience factors. Based on this science, they propose an “ecobiodevelopmental framework” from which the clinicians of the future should approach primary care.
REFLECT: What potential roles can clinicians take in responding to and preventing toxic stress?
GOAL: With deepened understanding of the prevalence and effects of childhood trauma, describe universal concrete actions that can be taken during the interview and exam to maximize emotional safety for patients.
This article was also provided in Immersion; it is provided here for clinical correlation. Ravi and Little discuss trauma-informed care as a “…universal precaution to optimally address patient’s health care needs while decreasing the risk of traumatization.”
REFLECT: Have you seen these precautions taken in your clinical settings?
Discussions about race and racism can be inherently uncomfortable. Acts of racism can take all forms and it is important to consider intent versus impact when racist behavior is exhibited. Much of this is driven by societal norms and socialization.
This video in an excerpt from the 1994 film The Color of Fear. Eight men of different backgrounds, races and ethnicities were gathered by director Lee Mun Wah, for a dialog about the state of race relations in America as seen through their eyes. This is a response by David C. after hearing about experienced racism from other members of the group.
Your goal for each activity
Create a personal definition of white fragility.
Understand how societal norms can lead to power differentials that exist between racial groups.
Create a framework for discussions that may be difficult or challenging.
Create a framework for understanding why talking about racism may be more difficult for some than others.