Bioethics Perspective II Race and Racism in Access to Healthcare

Differential treatment based on race or the group to which one belongs is an ethical problem because such treatment usually has a negative impact on life opportunities, education, and physical and mental well-being. African Americans have always been sicker and lived fewer years than whites; they have historically had—and continue to receive—differ-ent, unequal, and inferior access to healthcare. The prestigious Institute of Medicine's (IOM) March 2002 report evaluated over 100 studies focusing on health disparities published over the previous ten years. The IOM panel found that minorities who have the same income, education, medical conditions, and insurance as whites still receive poorer care than do the latter, showing that race is a significant variable in the health and healthcare of African Americans. Even though heart disease is a top killer of African Americans, whites get more aggressive treatment. Blacks with coronary heart disease are significantly less likely than whites to undergo bypass surgery, angioplasty, and a host of other services and procedures. Differential and racist treatment regarding kidney transplants, intensive care unit (ICU) treatment, and even the kind of information provided to pregnant women of different races have all been thoroughly documented.

Differential treatment is illustrated in government programs that provide health insurance for poor people on

Medicaid, elders insured by Medicare, and U.S. veterans. In these systems, no money is passed between patient and provider; thus, one assumes that patient enrollees in these three programs would be treated fairly, regardless of race. Studies of the distribution of services under all three programs show that blacks get a lower quality of care that whites. Under Medicare Managed Care, African Americans are less likely to receive breast cancer screening, diabetic eye examinations, beta-blockers for myocardial infarction, and mental health follow-up (Schneider, Zaslavsky, and Epstein). In Veterans Administration (VA) hospitals, black U.S. veterans get substantially fewer treatments for Acute Myocardial Infarction (AMI) than do white veterans and are less likely to undergo cardiac catheterization and to receive coronary bypass surgery (Peterson et al.). Medicaid too offers differential and substandard treatment to people of color. African-American children have a disproportional incidence of asthma; prevalence is twice that of whites, and death rates between 1980 and 1993 were four to six times higher (Centers for Disease Control, 1997; National Institute of Allergy and Infectious Diseases). Yet black and Latino children with worse asthma status are prescribed fewer preventive asthma medications than are white children within the same managed Medicaid plan (Lieu, Lozano, and Finkelstein).

Government programs also perpetuate disparities in health status and access to services in other ways. Due to federal medical criteria, African Americans receive proportionately fewer kidneys and they wait twice as long for them as whites. World-renowned transplant surgeon Thomas Starzl and his colleagues report that the national kidney allocation system inherently favors white patients because of the heavy emphasis placed on donor-recipient compatibility. They argue that antigen matching should not weigh so heavily in deciding who gets a kidney since differences in survival rates (the justification for current donor allocation) are negligible (Starzl, Aliasziw, and Gjertson).

Whether disproportional access to healthcare and services is intentional, it is clear that race is a factor in the delivery of healthcare in the United States. Although discussions of racism in healthcare and services have been prominent in other academic disciplines, it has been insufficiently explored in the area of bioethics. Differential treatment in access to healthcare is unassailably a bioethics issue.

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