The disproportionate impact of the COVID-19 pandemic on patients from historically marginalized racial and ethnic groups cast new light on health inequities, adding urgency to calls for changes to how physicians are trained and health care is delivered.
Throughout the pandemic, the AMA Code of Medical Ethics provided all-important ethical guidance on how to provide equitable care, including through Principle IX of the AMA Principles of Medical Ethics, which enjoins physicians to “support access to care for all people.”
Nevertheless, “additional guidance is needed to explicitly address the ethical implications of social forces that drive how and to whom health care is provided,” according to an AMA Council on Ethical and Judicial Affairs report whose recommendations were adopted at the 2023 AMA Annual Meeting.
“To make meaningful progress in achieving equitable care, physicians must recognize how the pathologies of social systems impact their patients’ lives,” said AMA Trustee David H. Aizuss, MD. “The commitment to serve patients in need means that we have an obligation to examine prevailing attitudes, habits, policies and practices that determine what care is available to who and to take steps to remove or re-engineer obstacles that undermine the ability to ensure equitable care for all.”
It’s everyone’s responsibility
To better outline the joint responsibilities that physicians and health care institutions have to ensure that they promote equitable care, the House of Delegates adopted policy setting out that:
Medicine at its core is a moral activity rooted in the encounter between a patient who is ill and a physician who professes to heal. The 'covenant of trust' established in that encounter binds physicians in a duty of fidelity to patients. As witness to how public policies ultimately affect the lives of sick persons, physicians’ duty of fidelity also encompasses a responsibility to recognize and address how the policies and practices of the institutions within which physicians work shape patients’ experience of health, illness and care.
As the physical and social settings of medical practice, hospitals and other health care institutions share the duty of fidelity and, with physicians, have a responsibility to ensure that the care patients receive is safe, effective, patient centered, timely, efficient and equitable.
Enduring health disparities across patient populations challenge these duties of fidelity. Disparities reflect the habits and practices of individual clinicians and the policies and decisions of individual health care institutions, as well as deeply embedded, historically rooted socioeconomic and political dynamics. Neither individual physicians nor health care institutions can entirely resolve the problems of discrimination and inequity that underlie health disparities, but they can and must accept responsibility to be agents for change.
The policy goes on to state that, in their individual practices, “physicians have an ethical responsibility to address barriers to equitable care that arise in their interactions with patients and staff.” They should therefore:
- Cultivate self-awareness and strategies for change; for example, by taking advantage of training and other resources to recognize and address implicit bias.
- Recognize and avoid using language that stigmatizes or demeans patients in face-to-face interactions and entries in the medical record.
- Use the social history to capture information about non-medical factors that affect a patient’s health status and access to care to inform their relationships with patients and the care they provide.
It adds that, within their institutions, “as professionals with unique knowledge, skill, experience and status, physicians should collaborate with colleagues to promote change” in the following ways:
- Support one another in creating opportunities for critical reflection across the institution.
- Identify institutional policies and practices that perpetuate or create barriers to equitable care.
- Participate in designing and supporting well-considered strategies for change to ensure equitable care for all.
The newly adopted ethics policy also makes recommendations to hospitals and other health care organizations, which it says “share medicine’s core values and commitment of fidelity, and with it ethical responsibility to promote equitable care for all. Moreover, as entities that occupy positions of power and privilege within their communities, health care institutions are uniquely positioned to be agents for change.”
These health care organizations should:
- Support efforts within the institution to identify and change institutional policies and practices that may perpetuate or create barriers to equitable care.
- Engage stakeholders to understand the histories of the communities they serve and recognize local drivers of inequities in health and health care.
- Identify opportunities and adopt strategies to leverage their status within the community to minimize conditions of living that contribute to adverse health status.
“Neither individual physicians nor health care institutions can entirely resolve the problems of discrimination and inequity that underlie health disparities, but they can and must accept responsibility to be agents for change,” Dr. Aizuss said.
Read about the other highlights from the 2023 AMA Annual Meeting.