Community/Public Health Nursing 6th Edition by Mary Nies ,Melanie McEwen

Exercise 4

Because public health is a societal approach to protecting and promoting health that usually acts through social rather than individuals means (Kass, 2001), many of the most pressing ethical dilemmas are considered in public domains. Perhaps no more important ethical challenge facing our public today revolves around the just distribution of health care resources.
For example, among 34.6 million rural minority adults in 2000, 32% of black, 35% of "other" race persons, and 45% of Hispanics were uninsured, compared with only 18% of whites (Glover et al, 2004). These data may help explain why minorities are more likely to be denied authorization for care (Lowe et al, 2001), to use less prenatal care (Barfield et al, 1996), and to make fewer visits to physicians (Tai-Seale, Freund, and LoSasso, 2001).
Differences in care resulting from patient or care process-level variables (e.g., patient attitudes, preferences or expectations, provider bias, stereotyping, or uncertainty) are problems of professional ethics. Disparities in care resulting from system-level variables, such as financing, accessibility and geographical location, are problems of justice (Institute of Medicine, 2003). Subsequently, solutions for justice issues in disparities in care require public discourse aimed at solving system level problems.
From an ethical perspective, the theory of justice as fairness was formulated to specify terms of social cooperation that are "fair" and ensure that people of equal basic liberties have equal opportunity (Daniels, Kennedy, and Kawachi, 1999). The Civil Rights Act of 1964 specifically bars discrimination in health care for all entities that receive federal funds, and both the American Nurses Association and American Medical Association codes of ethics endorse the principle of justice. However, despite overall agreement that justice is an important practice concept, difficulty arises in implementing changes in the health system to address disparities in care.
Solutions to disparities in care have been suggested by the Institute of Medicine (2003) and include the following policy, health system, and patient education and empowerment interventions.
Policy Interventions
Medical care financing should discourage fragmentation of health care into separate tiers of providers who adhere to different standards of care and serve separate racial and ethnic minority segments of society. Government programs that require enrollment in managed care should be prepared to pay plans at rates comparable to those paid to plans for privately insured patients.
2. Strengthen the stability of patient-provider relationships in publicly funded health plans and create policy to create consistency, limit patient loads for providers, and provide reasonable time allowances for initial and follow-up visits.
3. Increase the proportion of underrepresented U.S. racial and ethnic minorities among health professionals.
4. Apply the same managed care protections to publicly funded health maintenance organization (HMO) enrollees that apply to private HMO enrollees.
5. Provide greater resources to the U.S. Department of Health and Human Services Office for Civil Rights to enforce civil rights laws.
Health Systems Interventions
1. Promote the consistency and equity of care through evidencebased guidelines. These guidelines should be published to allow public and professional scrutiny.
2. Construct payment systems to enhance available services to minority patients, and limit provider incentives that may promote disparities.
3. Enhance patient-provider communication and trust by providing financial incentives for practices that reduce barriers.
4. Support the use of interpretation services where community need exists.
5. Institute programs that use community health workers among medically underserved and racial and ethnic minority populations.
6. Support greater use of multidisciplinary treatment and preventive care teams to improve and streamline care for racial and ethnic minority patients.
Patient Education and Empowerment Interventions
1. Implement patient education programs to increase patients' knowledge of how to access care and participate in treatment decisions.