Patients’ Race, Insurance Status Affect Likelihood of Ethics Consult
July 1, 2023
As a resident trainee, Aleksandra Olszewski, MD, MA, noticed patients from historically minoritized groups seemed to receive ethics consultations frequently. Additionally, conflicts that led to the ethics consults stemmed from cultural or communication differences between clinical teams and families.
To learn more, Olszewski and colleagues compared 209 cases of patients hospitalized from 2008 to 2019 who received an ethics consult, with 836 similar cases without an ethics consult. Patients identifying as Black, Hispanic, with public insurance or no insurance, and using Spanish language for care were significantly more likely to undergo ethics consults than patients identifying as white, those with private insurance, and those using English for care.1 Ethics consults were more frequent in historically minoritized groups by race/ethnicity, in groups that face language barriers, and among patients and families of lower socioeconomic status.
“I wondered if this reflected a difference in the prevalence of ethical dilemmas, or if there was a different use of ethics consultation due to clinical team bias,” says Olszewski, a pediatric critical care fellow at Ann & Robert H. Lurie Children’s Hospital.
Researchers did not examine reasons for the disparities in ethics consults. One possibility is disparities affecting clinical care generally are causing more ethical dilemmas, according to Olszewski. The ethical dilemmas could be happening more often for certain demographic groups because of inequities that occur before the hospitalization. If patients in certain groups are sicker, are managing more complex diseases, and are receiving high-intensity care, ethical dilemmas are more likely to happen. “Ethics consults could serve as a tool to address the ethical issues that arise as a result of these potential health inequities,” Olszewski says.
Another possibility is pre-existing biases among clinical teams result in certain patients, and not others, receiving ethics consults. “Clinicians can be mindful of their potential biases when considering ethics consultation,” Olszewski offers.
There are disparities in the way clinicians respond to conflict in historically minoritized patient populations, with more calls to security, more behavior contracts, and more restraint use.2-4 Similarly, clinicians might be quicker to request an ethics consultation as a response to conflict with these patient groups. “A major role of ethics consultants is conflict mediation. If there is more conflict incidence, and more poor communication, for historically minoritized populations, it makes sense that increased ethics consults may be one end result,” Olszewski explains.
Most consults in the study by Olszewski and colleagues involved care conferences. These meetings allow key stakeholders (i.e., the clinical team, ethicist, and family) to better understand each other’s perspectives and goals. “This could provide an opportunity to address potential oppression or bias that would otherwise be missed in ongoing clinical care,” Olszewski says.
Olszewski gives this hypothetical case example: The clinical team wants to know if the patient meets the criteria for brain death determination, but the family is not ready to consent for testing. Clinical team bias might contribute to clinicians giving a white family more time to decide before requesting an ethics consult. The same clinical team might call ethics right away if the case involves a family from a historically minoritized population.
Similarly, many ethics consults are called because of moral distress. Bias might lead the clinical team to be more likely to experience moral distress with patients from historically minoritized populations. “For instance, clinical teams may be more distressed about continuing care for a patient with poor neurologic outcomes if their family is one to whom they relate less, empathize with less, or have some bias against,” Olszewski observes.
More frequent ethics consults in a given patient population could be a signal of more ethical dilemmas, or more conflict, communication issues, or bias. Regardless of the reason, the fact that a group of patients is going through more ethics consults is not necessarily harmful. “In fact, the ethics consult can be used to have a positive impact,” Olszewski says.5,6
For ethicists, it can be a unique opportunity to address issues of inequity and bias in clinical care. “However, there’s potential for harm if ethicists fail to obtain the family’s perspective in their evaluation,” Olszewski cautions.
The ethicist’s analysis could be biased by the story presented by the clinical team. “The vast majority of ethics consultants are white, and ethics consultants themselves introduce a potentially biased perspective. This could contribute to biased care,” Olszewski notes.
Olszewski recommends simply considering the possibility of bias and equity concerns during consults. A simple way to do this is to develop a habit of asking the clinical team: “Are there any bias or equity concerns with this case?”
“It’s an opportunity for ethicists to educate clinical teams regarding whether their own biases are implicated in the decision to seek consultation,” Olszewski adds.
REFERENCES
1. Olszewski AE, Zhou C, Ugale J, et al. Disparities in clinical ethics consultation among hospitalized children: A case-control study. J Pediatr 2023; Apr 6;258:113415. doi: 10.1016/j.jpeds.2023.113415. [Online ahead of print].
2. Valtis YK, Stevenson KE, Murphy EM, et al. Race and ethnicity and the utilization of security responses in a hospital setting. J Gen Inter Med 2023;38:30-35.
3. Olszewski AE, Mendelsohn L, Paquette ET. Unique ethical and practical considerations in the use of behavior contracts for families of minors and minoritized populations in pediatric settings. Am J Bioeth 2023;23:82-85.
4. Nash KA, Tolliver DG, Taylor RA, et al. Racial and ethnic disparities in physical restraint use for pediatric patients in the emergency department. JAMA Pediatr 2021;175:1283-1285.
5. Campelia G, Olszewski AE, Brazg T, Vo HH. Transformative justice in ethics consultation. Perspect Biol Med 2022;65:612-621.
6. 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.
More frequent ethics consults in a given patient population could be a signal of more ethical dilemmas, or more conflict, communication issues, or bias. Regardless of the reason, the fact that a group of patients is going through more ethics consults is not necessarily harmful.
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