Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (2003) / Chapter Skim
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Racial and Ethnic Disparities in Healthcare: An Ethical Analysis of When and How They Matter
Racial and Ethnic Disparities in Healthcare: An Ethical Analysis of When and How They Matter
Pages 722-738
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From page 722... ...
Our first thesis, the neutrality thesis, is that disparities in health outcomes among patient groups with presumptively similar medical conditions should trigger moral scrutiny. Our second thesis, the antidiscrimination thesis, is that disparities in receipt of healthcare or adverse health outcomes among racial, ethnic or other disadvantaged patient groups should trigger heightened moral scrutiny.
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From page 723... ...
The neutrality thesis covers disparities in health outcomes among any patient groups with presumptively similar medical conditions and prognoses. By contrast, the anti-discrimination thesis refers specifically to a subset of what falls under the neutrality thesis the special case in which the outcome disparities involve racial, ethnic or other disadvantaged patient groups.
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From page 724... ...
Under the anti-discrimination thesis, disparities of either sort trigger an additional or heightened level of moral scrutiny beyond that warranted by health outcomes disparities generally. Moral Foundations for the Two Theses Thus far, we have merely articulated some of the implications of and analytic differences between the two theses and the implications of the differing forms of moral judgment that can flow from the use of either moral lens.
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From page 725... ...
Thus, even in the libertarian view, the failure of individuals and institutions to offer health services to all racial groups on an equal basis can be a significant basis for moral condemnation. A point of particular significance for this discussion is that nothing in the libertarian view necessarily excludes the existence of parallel moral obligations that are role specific, such as those ordinarily obtaining between physician and patient.
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From page 726... ...
The upshot is that the libertarian view, even in its strictest form, need not reject a thesis asserting that disparities involving racial and ethnic minorities should trigger special moral scrutiny. However, libertarians will locate their judgment of moral failing in the failure of specific individuals or institutions to discharge their moral duties, not in the society at large.
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From page 727... ...
If, as Daniels argues, health is especially strategic in the realization of fair equality of opportunity, and that healthcare services (broadly construed by Daniels) make a limited but important contribution to health, then we derive a right to healthcare sufficient to pursue reasonable life opportunities.
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From page 728... ...
Disparities in services received, no less than disparities in health outcomes, therefore trigger a heightened moral scrutiny under a theory that renders inequalities of both sorts morally problematic. Democratic Political Theory Libertarian and egalitarian theories are two broad theoretical traditions that at face value seem to have the greatest divergence in their implications.
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From page 729... ...
Thus, although there is a diversity of possible justifications for the importance of health and healthcare services, there is widespread basis for agreement that inequalities in health outcomes that track racial and ethnic lines, especially when racial and ethnic lines also track other indices of social disadvantage, are ethically problematic. This feature of democratic theory, reflected also in equal protection law, justifies at minimum the added moral scrutiny required by the anti-discrimination thesis.
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From page 730... ...
The libertarian views these consequences for the most part as merely unfortunate, not unfair. The libertarian view is an especially stringent rendering of the claim that moral responsibility for society and its political institutions is linked necessarily to a direct causal responsibility.
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From page 731... ...
Therefore, overt racist actions would surely count as intentional harms. For example, if services were not offered to racial and ethnic minorities because of a conscious intention to make their
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From page 732... ...
Brute Luck and Social Structural Egalitarian Views of Causality c, Other justice theories, including two prominent versions of egalitarianism, make the locus of causal responsibility an important consideration. Consider first a rather permissive standard sometimes referred to as the brute luck conception of justice (Scanlon, 1989~.
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From page 733... ...
Like the libertarian view, the social structural view demands proof that society had a causal hand in producing the inequality before it assigns society the moral responsibility for its elimination or reduction. The difference is that the social structural view does not require that the causal link between society and the inequality involve intentional harm.
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From page 734... ...
Even for these latter groups, a social structural view would necessitate the telling of a somewhat complex causal story to reach the conclusion that the inequalities are a matter of injustice and the responsibility of society to remedy. The Relevance of Individual Causal Responsibility A key question faced by libertarian, social structural, and brute luck theories is just how much of the causal story needs to be sorted out before deciding whether a disparity constitutes an injustice.
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From page 735... ...
If the preferences themselves are the fruit of a morally tainted history of institutional relationships, those who occupy positions of authority within those institutions have continuing moral obligations to ensure that patient preferences that are detrimental to racial and ethnic minorities are not systematically disadvantaging. In short, our view argues for looking behind or beyond mere preference in some instances to make a moral assessment of racial and ethnic disparities in the uptake of health services and in the resulting disparities in health outcomes.
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From page 736... ...
The capabilities approach does not generally insist on the complete causal story to count disparities in health outcomes as instances of injustice. Moreover, the capabilities view demands additional moral scrutiny for racial and ethnic disparities in healthcare services and outcomes for moral reasons that have their foundation in capabilities other than health.
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From page 737... ...
Even from a libertarian viewpoint, the failure of individuals and institutions to offer health services to all racial groups on an equal basis can be a significant reason for moral condemnation. In some respects, this is stating what is morally obvious.
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From page 738... ...
Kansas City, MO: American Nurses' Association. Cohen, GA.
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