A research study was just published, combining my newfound – and extremely personal – interest in chronic pain conditions with my longstanding passion for biomedical ethics. Often called bioethics, in North America.
For those reading this as patients (thank you!), the commonly accepted principles of biomedical ethics are:
- Respect for autonomy (taking into account a patient’s preferences and values)
- Beneficence (helping a patient; improving their health or well-being)
- Justice (treating patients fairly; also fair access to healthcare and medical services)
- Non-maleficence (not harming patients; with some exceptions, such as surgery, which cause harm with the aim of improving health)
The one I want to talk about today is justice; fairness. Although not specifically about discrimination, that principle does apply when any group is discriminated against in healthcare or medicine.
This new study looked at patients leaving the hospital, after being treated in the emergency room (ER) or emergency department (ED). And it looked at some specific medical conditions or health problems.
It found a difference between two different patient populations, or groups, for the types of pain medications prescribed when these patients were leaving the hospitals ED/ER.
Non-Hispanic Blacks” were less likely to have an opioid medication prescribed “for back pain and abdominal pain, but not for toothache, fractures and kidney stones, compared to non-Hispanic whites”(1).
Although this seems like something very negative for non-Hispanic black people, it might not be. The researchers even point out that this discrimination may be worse for white people:
Differential prescription of opioids by race-ethnicity could lead to widening of existing disparities in health, and may have implications for disproportionate burden of opioid abuse among whites.
The findings have important implications for medical provider education to include sensitization exercises towards their inherent biases, to enable them to consciously avoid these biases from defining their practice behavior”(1).
To be clear, I’m NOT saying that discrimination of any kind is okay! Just that it’s odd, that in this one case, it may actually lead to better health for black people than others. Which is really interesting, because that’s not usually how discrimination works…
This study is important, because to get rid of biases – which can lead to discrimination – we first have to identify them. That’s as true in healthcare as it is in education, policing, or any other area. If researchers can point to specific situations in which discrimination happens, then it will – I hope! – be easier to get rid of those underlying biases.
So now, as a next step, it will be important for researchers to try to find out why:
A black patient with the same level of pain and everything else being accounted for was much less likely to receive an opioid prescription than a white patient with the same characteristics”(2).
Again, I’m not saying that everyone should get a prescription for opioids for abdominal or back pain. I’m not a physician, and the researchers have stated that over-prescribing of opioids is a serious problem. Prescribing too much of anything can be dangerous.
The value of this type of research is that it also points to negative outcomes, worse health, for “non-Hispanic blacks” and probably for other groups too:
a problem as persistent as it is complex: Minorities tend to receive less treatment for pain than whites, and suffer more disability as a result”(3).
That’s not good; in bioethics terms, it’s unjust. It’s not fair. Although “complex”(3), this seems to stem from racial bias. Bias leads to stereotyping; when someone’s mind lumps groups of people together – often without even knowing that their brain is doing this.
Our brains like to create patterns, or groups of information. It makes it easier for a brain to remember things. That’s very important for doctors, nurses, pharmacists, and others working in healthcare. Because they have to remember so much information. And because patients depend on that, for their health.
Sometimes it’s a good thing, and not bias; for example doctors and nurses need to remember that African-Americans have some higher risks for blood pressure:
Researchers have also found that there may be a gene that makes African-Americans much more salt sensitive. In people who have this gene, as little as one extra gram (half a teaspoon) of salt could raise blood pressure as much as 5 mm Hg”(4).
And just as a brain can create a pattern like this one – that African-American patients may need more follow-up care or health coaching about salt and high blood pressure – we can train our brains to unlearn patterns they’ve created.
But that’s much harder to do. A starting point is knowing how the pattern crept into your brain. Let me take a personal example, to show you what I mean. When I go to a restaurant for supper, I always want to have dessert. Even if I’m not hungry, after my meal. So for years I’d order dessert, have a bite, and realize I couldn’t eat it. I just wasn’t hungry.
To change this, I had to find out why I feel this way. I had to figure out why my brain made a pattern – like a computer program or code – that went something like this: ‘Restaurant = Dessert’.
When did I first go to a restaurant for supper? As a kid, with my mom and sister; our dad worked night shifts back then so often wasn’t with us. What did our mother tell us? “If you finish your supper, you can have dessert.”
She made dessert a reward. So I’d eat really fast, in a hurry to get dessert. The reward. I wouldn’t even pay attention to what I was eating, or whether I was feeling full. I just focused on the prize, on dessert.
Once I figured that out, I was able to start to focus on the actual meal in a restaurant. Now I’ll often I’ll order 2 appetizers as a meal, so I can try different things. And really enjoy them. If I’m not hungry for dessert, that’s fine – I just steal a bite of my husband’s dessert , -)
But it was hard, to unlearn that pattern – or computer code – that my brain had taught itself. I had to keep reminding myself, for years. And yes, still order dessert sometimes, without thinking about it. Habits are really hard to break. Even for our brains.
So what I’m hoping is that research like this will help folks working in healthcare to think about what patterns their own brains have learned. And then try to pinpoint the source of any biases they have, which could lead to negative stereotypes.
This would let them work to change that, to actively re-train their brains to only act on racial or ethnic differences that are relevant to a person’s health. Like remembering that eating salty foods is more likely to impact blood pressure for African-Americans.
And hopefully medical schools can teach new doctors ways to avoid these biases and stereotypes. Along with schools of nursing, and pharmacy. In the meantime, each of us working in healthcare should remember that:
researchers have also found evidence of racial bias and stereotyping in recognizing and treating pain among minorities, particularly black patients.”(3)
IMAGE——– /SmartArt_Pain-descriptors.jpg === “a list of words used to describe pain”
References:
(1) Astha Singhal, Yu-Yu Tien, and Renate Y. Hsia. Racial-Ethnic Disparities in Opioid Prescriptions at Emergency Department Visits for Conditions Commonly Associated with Prescription Drug Abuse. 2016. PLOS ONE 11(8). Accessed 12 Aug 2016. Web:
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0159224
(2) Amanda Holpuch. Black patients half as likely to receive pain medication as white patients, study finds. The Guardian. 10 Aug 2016. Accessed 12 Aug 2016. Web:
https://www.theguardian.com/science/2016/aug/10/black-patients-bias-prescriptions-pain-management-medicine-opioids
(3) Abby Goodnough. Finding Good Pain Treatment Is Hard. If You’re Not White, It’s Even Harder. New York Times. 08 Aug 2016. Accessed 12 Aug 2016. Web:
(4) American Heart Association. High Blood Pressure and African Americans. Accessed 12 Aug 2016. Web:
https://www.heart.org/en/health-topics/high-blood-pressure/why-high-blood-pressure-is-a-silent-killer/high-blood-pressure-and-african-americans