Public Health Ethics: Case 3

Health Care Disparities and Priority for Treatment
(From BH509: When Life Makes You Sick: Ethics and the Social Determinants of Health, Erika Blacksher, instructor)

Samuel Banks is a 54-year-old accountant with a college degree and health insurance. He was the first of four children and a first generation college graduate. Having worked hard all of his life, Mr. Banks has been exposed to a variety of chronic stresses, including racism. As an African American growing up in the southeast United States, Mr. Banks was exposed to a steady stream of slights and insults as well as institutional forms of racism. Despite these challenges, he had been healthy much of his life even though he put on an extra 25 pounds in his late 40s. Over this past year he began to have heart issues. Initially, he thought he was just having heartburn, but the discomfort persisted. Mr. Banks visited his physician, who was new to him because his employer had just switched insurers. He had waited an hour in the waiting room and was agitated by the time he got to see Dr. Susan Mott. The visit did not last long. Dr. Mott was polite but hurried, facing a full waiting room of patients, and Mr. Banks perceived the doctor as rushed and rude. He left Dr. Mott’s office frustrated and determined to find a new physician. Before he could find one, he had a heart attack. He was rushed to the emergency room where he received medical treatment that included a physical exam, ECG, chewable aspirin, supplemental oxygen, nitroglycerin, and monitoring through the night. What he needed and did not receive, however, was coronary artery bypass graft surgery (CABG). This is not an uncommon experience for minorities. Members of racial and ethnic groups receive less and lower quality health care than their white counterparts. The Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care documents the extent of these disparities in health care and their potential sources (Geiger HJ et al. 2003).

Many people argue that health care disparities constitute an injustice. The argument can be made on a number of moral grounds, including the idea that people should be treated equally, regardless of race or ethnicity, receiving treatment only on the basis of medical need. Some commentators, however, have raised the question of whether disadvantaged patients should be given priority at the point of care.

Should the health care system prioritize care for members of disadvantaged groups over that of other patients? 
Should clinicians attempt to redress injustices in the social determinants of health by prioritizing the disadvantaged when they enter the health care system?