Bioethics Forum Essay

Ethicists as a Force for Institutional Change and Policies to Promote Equality

In his recent JAMA article, Donald Berwick eloquently describes what he termed the “moral determinants of health,”  by which he meant a strong sense of social solidarity in which people in the United States would “depend on each other for securing the basic circumstances of healthy lives,” reflecting a “moral law within.” Berwick’s work should serve as a call to action for bioethicists and clinical ethicists to consider what they can do to be forces of broad moral change in their institutions.

I believe that individuals can powerfully shape the ethos and values of the institutions where they work and therefore they have a moral obligation to tackle inequality and structural racism in their institutions and influence what their institutions do to confront these issues in society. Now is the time for those of us who are ethicists in health care and other organizations to leverage our thoughtfulness and use our influence with leadership and key stakeholders to be catalysts for change. It is not enough to document inequality and structural racism while ignoring the inherent injustices that persist and that, by our inaction, we condone. We must make a commitment to disrupt the widely accepted norms and current practices that contribute to inequality and structural racism and be prepared to make sacrifices and feel uncomfortable as we challenge the status quo. I have heard discussions about “allyship” at this time and a call to serve as an “accomplice.” An accomplice does more than express empathy and outrage; an accomplice takes action, and that is what we must do if we are truly committed to change and progress.

I am frustrated by the communications coming from health care and other institutions pledging solidarity and a determination to fight structural racism and inequality. Some of these places accepted bailout funds to support the salaries of rich CEOs and still furloughed many of their staff and continue to avoid considering what strategies they can implement to reduce inequality among their local populations and beyond. We cannot continue to tolerate institutional behavior that exacerbates disparities, whether through deliberate action or careless inaction. We should act as the conscience and integrity of institutions and force a revolution from within that manifests as true solidarity with practical and sustainable transformation.

What does that mean and how can it be realized? I welcome suggestions. For health care institutions, some of this change can happen when they examine their strategic priorities, practice, and policies and how they affect which patients are treated and who is marginalized. Health care institutions can also assess areas of clinical need in their communities. They can explore mechanisms to deliver high-quality care to underserved populations. Furthermore, institutions should critically examine how cost-cutting measures affect vulnerable employees, including the implications of shifting some employees to subcontractors  that provide inferior health insurance and minimal benefits. I would even go as far as to suggest that highly paid institutional leaders consider cutting their salaries to support these initiatives. Furthermore, institutions should use their standing to improve the community environment as a whole, rather than distancing themselves from the important factors that determine health outcomes, such as access to affordable healthy food and good schools. This means understanding day-to-day living conditions of people in their communities, such as where they buy food, where they go to school, and what opportunities are available to them. We need to avoid the temptation to shrug our shoulders and assume that we’re ill-equipped to do anything about the social determinants of health. The National Academy of Sciences, Engineering, and Medicine has outlined a framework to guide health care organizations on addressing the social determinants of health among their patients. We need to prompt our institutions to adopt and implement these approaches.

The Covid-19 pandemic and the killing of George Floyd have raised awareness that inequality is an enormous problem in the U.S. Most of us already knew this. That African-Americans and Latinos are disproportionately affected by Covid is tragic but sadly predictable based on evidence about the social determinants of health. (See here,  here, and here  for some of the many reports.)  I hope more ethicists will seize this moment and work for justice on behalf of all those who are disenfranchised by inequality and structural racism. These issues should be energizing bioethicists everywhere and causing “moral distress,” prompting us to lead the charge to change establishment norms, starting with the institutions where we work. I hope that this historical moment will be a stimulus for uncomfortable conversations and meaningful engagement that can significantly influence the “moral determinants of health” and reduce inequality.

Amelia K. Barwise, MB, BCh, BAO, PhD, is an assistant professor and research associate in the Division of Pulmonary and Critical Care Medicine at the Mayo Clinic Rochester. Her research focus is disparities in end of life care among patients with limited English proficiency.