Consult Services Should Address Racism and Bias
Hospitals are addressing health equity and combating racism in all areas, including ethics. At Seattle Children’s, the ethics consult service recently forged a new partnership with the hospital’s Center for Diversity and Health Equity (CDHE).
“We were motivated to share what we’d learned with other ethicists who might be considering similar modifications to their consult services,” says Kate MacDuffie, PhD, MA, a postdoctoral research associate at the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s.
Members of the ethics consult service developed recommendations for consultants to help address health equity and promote anti-racism, both in care of individual patients and in institutional policy.1 “Sharing experiences with colleagues at other institutions could have benefits for all working toward the communal goal of reducing racism in healthcare,” MacDuffie says.
When someone requests a consult with a health equity concern, at least one member of bioethics and the CD responds to interview stakeholders and generates recommendations. If an organizational-level health equity issue is identified, two bioethics consultants with organizational expertise also are involved.
Of 60 consults conducted from January 2020 to January 2021, one-quarter involved a health equity issue. Clinicians were concerned higher expectations were set for a Black/African American family to demonstrate skills for home care before a patient was discharged. Clinicians worried the organization’s single caregiver policy during the COVID-19 pandemic was disproportionately affecting non-English-speaking families. Also, clinicians and an American Indian teenager were in conflict regarding goals of care.
Individual and group work was needed to adapt the ethics consult service to address racism. “Individual ethics consultants, particularly those who themselves had never been the target of racism, needed to work to educate themselves and become more comfortable addressing racism directly,” MacDuffie says.
The ethics consult service set clear expectations for implementing the modifications to the consult process. “A strong commitment from leadership was essential,” MacDuffie notes.
Shika Kalevor, RN, MBE, a teaching fellow at Harvard Medical School Center for Bioethics, co-authored a paper with two colleagues, each with a background in nursing and ethics, on how to use everyday ethics to confront bias and racism in clinical care.2
“As a black ICU nurse, I faced many experiences in my personal and professional life that motivated me to pursue a master’s of bioethics in order to find solutions to the problems I witnessed and faced,” Kalevor says.
Kalevor and colleagues were motivated to mitigate bias and racism at the bedside by providing ethicists and clinicians with actionable steps. “All healthcare workers must be humble in recognizing that bias exists in everyone, and to take the initiative to address them,” Kalevor says.
Kalevor and colleagues emphasized the importance of recognizing ethical issues in the context of day-to-day clinical encounters. The paper highlighted shift reports as an opportunity to mitigate bias and act like an everyday ethicist.
“Each person has the opportunity to take steps toward change,” Kalevor says. “We hope this paper empowers not only nurses, but also other healthcare workers, to pay attention to these issues and address them when they appear.”
An independent anti-racism task force of bioethicists is collaborating with The Hastings Center as part of the center’s health equity initiative. Task force members examined structural racism, particularly anti-Black racism, in healthcare settings and in the field of bioethics itself in a recent special report.3
“We are combining our efforts and talents to bring this issue to light. We can no longer be silent on racism’s effects on health,” says Virginia A. Brown, PhD, a member of the task force and an assistant professor in the department of population health at the University of Texas at Austin Dell Medical School.
Brown suggests ethics committees discuss the special report with a facilitated conversation among its members. Ethics committees also can examine clinical outcomes, such as maternal/fetal outcomes with an emphasis on Black and Latinx patients, facilitated in partnership with Black and Latinx doulas, or analyzing housing and food stability, or access to smartphones or telehealth.
“Improved clinical outcomes can only begin by recognizing and responding to racism’s role in creating and sustaining health inequity,” Brown says.
During every ethics consult, Brown says ethicists should identify if there is bias. “Asking ‘What structural barriers are potentially impacting this case?’ when engaged in case consultations puts this inquiry front and center,” says Brown, who co-authored a paper on how ethicists can address anti-Black racism.4
Ethicists can be involved in examining recruitment, retention, and promotion polices, and whether clinical areas are using minority vendors and providing mentorship opportunities. “Work such as this cannot be left to the organization alone. It’s like asking the fox to guard the hen house,” Brown says.
- MacDuffie KE, Patneaude A, Bell S, et al. Addressing racism in the healthcare encounter: The role of clinical ethics consultants. Bioethics 2022;36:313-317.
- Kalevor S, Uveges MK, Meyer EC. Using everyday ethics to address bias and racism in clinical care. AACN Adv Crit Care 2022;33:111-118.
- Fletcher FE, Ray KS, Brown VA, Smith PT. A critical moment in bioethics: Reckoning with anti-black racism through intergenerational dialogue. April 26, 2022.
- Fletcher FE, Ray KS, Brown VA, Smith PT. Addressing anti-black racism in bioethics: Responding to the call. Hastings Cent Rep 2022;52:S3-S11.
Hospitals are addressing health equity and combatting racism in all areas, including ethics. Members of an ethics consult service can develop recommendations for consultants to help address health equity and promote anti-racism, both in care of individual patients and in institutional policy.
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