BY: EVERARD O. RUTLEDGE, PhD, FACHE
Dr. Rutledge is vice president, Community Health, Bon Secours Health System,
Studies Show that Women and African Americans Often Get Inferior Care
The events of September 11, 2001, and its aftermath have affected U.S. society
in a multitude of ways. One unfortunate reaction is our suspiciousness of people
of foreign origin, especially those of Islamic descent. A more fortunate reaction
is our new awareness that the United States is a multicultural society—not so
much a "melting pot" as an "alphabet soup" culture. A recent editorial in US
Airways Attache noted that between 1990 and 1998 the population of metropolitan
Washington, DC, grew by 250,000 legal immigrants, from 193 different countries.1
What are the implications for us?
What, especially, are the implications for health care? Before September 11,
we Americans generally felt that we provided the best possible health care service
to any person who sought it. Was that the case? More important, is it the case
now? Have we really kept a blind eye to people's backgrounds, ethnic origins,
Inequality of Health Care
The recent report issued by the Institute of Medicine (IOM), Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health Care,2 gives
irrefutable evidence of inequality in the delivery of health care. Those of
us—physicians, nurses, technicians, administrative personnel—who work for Catholic
organizations must especially ask ourselves whether cultural, racial, or ethnic
bias affects the way we deliver care. We are called not only to conform to civil
law and codes of professional ethics but also to the Ethical and Religious
Directives for Catholic Health Care Services and to the articulated values
of our particular Catholic organizations.
We have traditionally believed that those who come through our doors are given
care without regard to background, ethnicity, race, religion, or national origin.
Unfortunately, the data concerning access to care do not necessarily bear this
out. The IOM report should occasion serious discussion, debate, and, finally,
substantive action on the important—but too often unnoticed—effect that unequal
access and treatment have on our society.
In a recent article, I noted that inequality of access has in fact existed
in U.S. health care institutions for some time.3 In 1999, for example,
racist remarks made by radiologists at an Atlanta hospital were inadvertently
captured on tape and given to a medical transcriber. Learning of these remarks,
John Ed Fowler, MD, president of the Medical Association of Georgia, said, "The
patient-doctor relationship is the chief principle in our code of ethics, and
the action of these physicians is simply unacceptable. . . .Physicians who break
this trust with their patients should not be practicing. . . .Whether unequal
medical treatment is caused by differences in income and education or social
and cultural factors, [it is] unjustifiable and will not be tolerated [by the
One hopes that the race of patients will not cloud the judgment of the physicians
who treat them, thereby resulting in unfair treatment. All practitioners have
a responsibility to exercise the best medical judgment and make the best treatment
decisions, regardless of patients' race, gender, age, or other extraneous factors.
After all, practitioners have taken an oath to provide care to all who seek
Not-for-profit institutions are governed by their charter as a public trust
to ensure that everyone who enters their doors should be treated with dignity
and respect, even if that means transcending institutional policies and practices
that have failed to take demographic changes into account. It is true that health
care institutions are merely microcosms of the greater society. Because our
society is a multicultural one, the people who operate health care facilities
may have different values than those who seek treatment in them; such differences
may affect the treatment given. Most of us who work in Catholic facilities know
we must respond to a higher standard, ensuring that all staff adhere to expected
values and ethical responsibilities and treat patients equally. This is not
true everywhere, however. A 1993 study published in JAMA suggested that
race, rather than financial capability, was the primary factor affecting the
type of treatment offered to minority patients in Veterans Affairs health care
These studies [the authors concluded] have shown that white patients are
more likely than black patients to undergo various invasive cardiac procedures,
such as cardiac catheterization, percutaneous transluminal coronary angioplasty
(PTCA), and coronary artery bypass grafting (CABG). These differences persist
despite adjustment for potential confounding variables such as age, sex, clinical
factors, socioeconomic status, and insurance status.6
A study described in the New England Journal of Medicine endeavored
to determine if race and sex were factors in the use of reperfusion therapy
for patients who had had myocardial infarctions. According to the authors:
In this national sample of 25,575 Medicare beneficiaries . . . white women
were as likely as white men to receive reperfusion therapy . . . However,
blacks, regardless of sex, are significantly less likely than whites to receive
this potentially lifesaving therapy. . . . [A] likely explanation for our
findings is that the decisions of physicians, as a result of clinical ambiguity,
lack of adequate training, insufficient knowledge, or physicians' own preferences
or biases, contributed to the racial differences we observed in this study.7
One cannot have a thorough discussion of the issues related to diversity without
mentioning disparities in the care of women. Many people assume that the word
"diversity"concerns only race or ethnicity. Nothing could be further from the
truth. The available literature makes it quite clear that the care received
by men differs from that received by women, including women of European descent
as well as those of other ethnic backgrounds. An article in the New England
Journal of Medicine described differences found among men and women who
had had hip or knee replacement surgery because of severe arthritis. The authors
although women were more likely than men to seek treatment for arthritis
and had similar levels of self-reported coexisting conditions, women with
a potential need for arthroplasty were less likely than men to report having
ever discussed arthroplasty with a physician. These findings are provocative
and suggest that a possible explanation for the observed sex differences in
the potential need for arthroplasty may be that women are less likely to be
referred, or perhaps are referred after a longer interval, to orthopedic surgeons
for consideration for arthroplasty.8
There may be a number of reasons for this apparent inequity, ranging from
insufficient communication between the patient and the caregiver, on one hand,
to physicians' views concerning the suitability of candidates for particular
surgeries, on the other. Nevertheless, a good deal of data suggests that women
tend to be discriminated against when it comes to the arthroplasty procedures
described in the article.
Despite the strides that women have made over the past decade and a half,
moving into positions of influence and increasing their numbers as health care
providers in both community and academic settings, statistics show that they
continue to get inferior care for a range of problems, including heart disease,
diabetes, osteoporosis, Alzheimer's disease, breast cancer, and domestic violence.
Disturbing also are the differences seen among women patients themselves. As
a former U.S. surgeon general has noted, "If we look at death rates for diseases
of the heart, African-American women are clearly at risk, with a staggering
147 deaths per 100,000, compared to 88 for white women, 70 for American Indian/Alaska
Native women and 63 each for Hispanic women and#Asian-American/Pacific Islanders."9
We know that mortality and morbidity data are affected by genetic and cultural
influences. But the perspectives, competence, and behavior of practitioners
are significant factors as well. It is imperative that we who work in health
care be neither shy nor defensive about our quest for the truth regarding the
behavioral, genetic, environmental, and occupational factors that influence
our current health care delivery system.
Reflecting on this issue is unsettling, especially for those who, like us,
serve faith-based organizations. Knowledge of such disparities is so disturbing
that it may rock our sense of fairness as it concerns quality in treatment and
clinical outcomes. We all like to think that when we present ourselves to a
provider, we will encounter no bias regarding race, gender, nationality, or
other medically irrelevant factors in the consideration of treatment options.
The inequalities discussed here are not always a reflection of prejudice or
preconceptions on the part of institutions or practitioners. Lifestyle, heredity,
education, compliance, and other related socioeconomic factors also affect outcomes.
Even so, the evidence suggests that different kinds of people receive different
medical services and that some groups have less access to advanced medical technology
than other groups. Some authorities would argue that racial bias is the only
primary reason for the health disparities seen in the epidemiological and biostatistical
data. One must agree that there is enough evidence to conclude that both behavioral
and environmental factors contribute to different outcomes. These differences
should be addressed vigorously.
Bon Secours' Statement
The reality is that health care providers are human. Human dynamics—background,
experience, learned and unlearned behavior—affect every aspect of our lives,
manifesting themselves in countless ways in our actions and interactions with
each other. These dynamics are certainly involved in such issues as diversity,
hiring, promotion, and others. Therefore, we who serve Catholic health care
can expect thoughts and sentiments that are inconsistent with our ministry's
mission, vision, and values to occasionally creep into our actions. Precisely
because this is so, we must focus on this important issue.
The Ethical and Religious Directives importantly articulate several
dimensions of this matter. Indeed, our awareness of this issue needs to be heightened.
At a minimum, we should begin a dialogue on how to deal with the impact of bias
as it affects both the provision of care to certain populations and the clinical
outcomes of that care. As Directive 3 puts it:
In accord with its mission, Catholic health care should distinguish itself
by service to and advocacy for those people whose social condition puts them
at the margins of our society and makes them particularly vulnerable to discrimination:
the poor, the uninsured and the underinsured; children and the unborn; single
parents; the elderly; those with incurable diseases and chemical dependencies;
racial minorities; immigrants and refugees. In particular, the person with
mental or physical disabilities, regardless of the cause or severity, must
be treated as a unique person of incomparable worth, with the same right to
life and to adequate health care as all other persons.10
The "Shared Statement of Identity for the Catholic Health Ministry," developed
by members of the Catholic Health Association (CHA), emphasizes the importance
of this topic for participating organizations.11 One CHA member,
Bon Secours Health System, Inc., (BSHSI), Marriottsville, MD, stresses Catholic
identity in its Values and Operating Principles statement, which includes a
pledge to "promote and defend human dignity." Because (the pledge continues)
"each person is created in the image of God (Gn 1:27), each one is sacred and
possesses inalienable worth, and is social by nature and finds fulfillment in
and through community. Catholic healthcare, therefore, treats individuals—and
their families and various communities—with profound respect and utmost regard."12
BSHSI further promises to "promote each person's dignity (worth) and we defend
their dignity and their right to reach their potential. This belief is the basis
for the BSHSI Values of respect and growth and its Operating Principle
of superior understanding of those we serve."
In a continuing series of bullet points, the BSHSI statement also promises
• Care for Poor and Vulnerable Persons: Because Jesus had a special
affection for poor and vulnerable persons (Mt 25:34-40), Catholic healthcare
distinguishes itself by service to and advocacy for those people whose social
condition puts them at the margins of our society and makes them particularly
vulnerable to discrimination. Catholic healthcare is characterized by its
efforts to alleviate the conditions that perpetuate the structures of poverty
and vulnerability in society. . . . It is essential that BSHSI always consider
and serve the needs of those who are poor, dying, vulnerable and on the margins
of society. The BSHSI Value of justice deals with this imperative and
the commitment to unmet needs is the corresponding Operating Principle.
• Act on Behalf of Justice: Because justice is an essential component
of the Gospel of Jesus (Mt 5:1-12), Catholic healthcare strives to create
and sustain right relationships both within the ministry and with those served
by the ministry. Toward this end, Catholic healthcare attends to basic human
needs for all (including accessible and affordable healthcare) and seeks structures
that enable the full participation of all in society, the equitable distribution
of societal resources, and the contribution of all to the common good. . .
. BSHSI strives to create and sustain right relationships within the organization
and with those whom we serve. We promote, defend and advocate for the rights
of all people and for the common good. The BSHSI Value of justice supports
this belief and action.
As we who serve Catholic health care reflect on our stewardship and review
our organizational initiatives, we must be mindful of our community needs and
especially aware of the quality of our services. We must look closely at the
needs of all who come through our doors and view them in light of quality indicators
as part of our overall quality program. At BSHSI, in accordance with our Ethics,
Care of the Dying and Diversity Quality Plans, we are developing accountable
systems that acknowledge our progress toward high-quality care. We intend these
plans to be responsive to the local unique universe of our patients' particular
How do we in Catholic health care address the challenges involved in serving
diverse populations? As we continue to expend considerable resources on information
technology to evaluate clinical quality for the Joint Commission on Accreditation
of Healthcare Organizations and other entities, it will become increasingly
necessary for us to "slice" our data in ways that reflect the race, ethnic and
social backgrounds, and genders of our patients. Some will question the need
for more data. But if we are to live up to our values, we will need such data
to keep from being lulled into a false sense of security about what we are doing
in our institutions. Alignment with our stated values can be measured, at least
in part, by quantitative clinical data.
But information and decision support systems must mature to become more integrated.
It is no longer enough to have strong financial, human resource, and clinical
care systems that are not capable of disaggregating the data into descriptive
patient-specific slices. A strong clinical care information system would allow
us to better address key ethical and public policy challenges. To leverage clinical
data in this public discussion, we must integrate these systems into public
health databases, report them on "community report cards," and make them an
integral part of our strategic planning processes. Although capturing such data
may be initially difficult, we will, by doing it, enhance our ability to report
and analyze outcomes. As the authors of an article on the subject noted several
Demand for evidence-based accountability is an outcomes-management reporting
system [including] internal continuous quality improvement in real time, external
reporting and accountability to multiple groups, and tracking patients over
time to assess trends and examine the long-run impact of improvement interventions.
. . . External reporting requirements will be driven by such organizations
as the National Committee for Quality Assurance and the Joint Commission on
Accreditation of Healthcare Organizations. This will require aggregating data
across patients and physicians to derive intermediate and outcome measures
of both service and clinical quality such as immunization rates, mammography
screening, and selected risk-adjusted morbidity and mortality rates. . . .
Clinical information will become the lubricant for outcomes reporting, and
outcomes reporting in turn will be at the heart of accountability between
physicians and multiple stakeholders. 13
We must look our respective communities in the eye and say, "When you come
to our doors, you will be assured that opportunities for services are not reflective
of race, gender, or economic biases." The outcomes may not be the same for all
patients—because, as we've noted, heredity, educational background, and lifestyle
choices, among other factors, do have an impact on health status. But we can
assure all patient populations that everyone will be afforded the same advanced
technology. For Catholic health care systems, public assurance is a matter both
of advancing the common good and of respecting the dignity of all who come to
us for care.
Opportunities for launching such a public dialogue will be accompanied by a
great deal of emotion and heated debate from numerous organizations (e.g., community-based
groups, physicians, trade groups). We are all aware of the fact that most of
the care at the institutional level is driven by individual private practitioners.
We must encourage those individual members of our medical staffs to use their
skills in a manner that is nonbiased. To say the least, this will be a sensitive
topic with which to approach staff physicians; but we must approach them. After
all, members of a medical staff are people who, like the rest of us, inevitably
reflect the mores of the larger society, bringing their backgrounds, experiences,
philosophies, and biases to their medical practice. Evidence of this can be
seen in the Associated Press's report of the incident at the Atlanta hospital
Three [radiologists] were barred from working at a hospital and fired from
a radiology practice for making racist remarks that were caught on a hospital
tape recorder that they thought was shut off. [A fourth radiologist named
in the lawsuit was cleared.] The comments were recorded by a medical transcriber
. . . who sued the doctors, Atlanta Medical Center, a radiology contractor,
and a transcription company. [The medical transcriber], who is black, alleged
she was fired after she complained. . . . One doctor used a racial epithet
to refer to blacks, and the others made disparaging comments.14
Of course, human motivation is shaped by many factors: economic, cultural,
geographic, religious, and others. I do not want to suggest that white physicians
alone are the problem, for they are not the only ones guilty of insensitive
or discriminatory behavior.
Social considerations—including wealth and status in the community—influence
the way some practitioners relate to their patients, as do the practitioner's
orientation, training, and geographical origins. I have frequently heard nonwhite
people describe the caregivers they encountered in hospitals and emergency rooms
as "indifferent," "uncaring," "unresponsive," and "uncommunicative." The caregiver
just "doesn't hear me," they often say. Of course, the vast majority of physicians,
nurses, and technicians do not behave this way. But too many do.
Because they have not always been treated respectfully, some populations tend
to avoid hospitals and physicians and, as a result, sometimes develop misconceptions
about health and health care. One writer, aware of this tendency, urges clinicians
determine whether patients' fundamental assumptions about the risks and
benefits of medical interventions are accurate. Misinformation should be corrected.
This process should be incorporated into the education of medical students,
resident physicians, and the continuing education of practitioners. These
strategies ultimately should help patients make authentic choices that are
truly guided by informed decisions and not limited by truncated opportunities
or historical circumstance. 15
One can only hope that we health care providers act on the issues and challenges
outlined in Unequal Treatment as we have acted on those discussed in
the IOM's previous reports, Crossing the Quality Chasm and To Err
The Catholic Health Care Mission
Although all health care organizations should address possible disparities
in access and treatment, the issue is especially pressing for Catholic organizations.
As my colleague Ed Gerardo, chief development officer, Bon Secours St. Francis
Medical Center, Midlothian, VA, has put it:
For Catholic health care providers today, the challenge of discerning the
proper course of action is all the more exacting because of the nature of
the activity and the values inherent in a religious organization. . . . Good
quality care is the essential and tangible reflection of a provider's intent
to honor the dignity and promote the well-being of the person. Moreover, although
all providers are expected to go beyond corporal concerns and attend to patients'
emotional and spiritual needs, faith-based providers have an expressed accountability
to patients and families to provide the necessary services that address these
Those who provide health care in a faith-based setting should take care to
align care delivery with their organization's stated mission and values. For
Catholic organizations, such alignment clearly requires a demonstrated commitment
to the dignity of every person, to social justice, and to advancement of the
Catholic organizations should engage in a formal process of self-reflection,
reviewing their clinical and administrative practices in light of these values
and mandating improvement where those values are not being honored in day-to-day
practice. In cases where racial, cultural, or gender bias is found to interfere
with care delivery or treatment, a truly values-based organization will take
prompt and compassionate action to see that such interference comes to an end.
- Stephen M. Wolf, "Our Changing Face," US Airways Attache, March 2002,
- Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson, eds., Unequal
Treatment: Confronting Racial and Ethnic Disparities in Health Care, Institute
of Medicine, Washington, DC, 2002.
- L. Everard O. Rutledge, "The Struggle for Equality in Healthcare Continues,"Journal
of Healthcare Management, September-October 2001.
- Rutledge, pp. 314-315.
- Rutledge, p. 315.
- J. Whittle, et al., "Racial Differences in the Use of Invasive Cardiovascular
Procedures in the Department of Veterans Affairs Medical System,"JAMA,
August 26, 1993, pp. 621-627.
- John G. Canto, et al., "Relation of Race and Sex to the Use of Reperfusion
Therapy in Medicare Beneficiaries with Acute Myocardial Infarction,"New
England Journal of Medicine, April 13, 2000, pp. 1,097-1,098.
- Gillian A. Hawker, "Differences between Men and Women in the Rate of Use
of Hip and Knee Arthroplasty," New England Journal of Medicine, April
6, 2000, p. 1,020.
- David Satcher, "American Women and Health Disparities,"Journal of the
American Medical Women's Association, Fall 2001, p. 131.
- U.S. Conference of Catholic Bishops, Ethical and Religious Directives
for Catholic Health Care Services, Washington, DC, 2001, p. 9.
- Catholic Health Association, "A
Shared Statement of Identity for the Catholic Health Ministry,"St. Louis,
2001; see for the statement and a description of its development.
- "Catholic Identity Resource Tool, Version 1.0,"Bon Secours Health System,
Marriottsville, MD, September 2001.
- Stephen M. Shortell, et al., "Physicians as Double Agents: Maintaining
Trust in an Era of Multiple Accountabilities,"JAMA, September 23, 1998,
- "Doctors Fired over Racist Remarks," Associated Press, Atlanta, October
- Jeffrey N. Katz, "Patient Preferences and Health Disparities,"JAMA,
September 26, 2001, p. 1,508.
- Edward F. Gerardo, "Organizational Ethics Case Study: The Bon Secours Richmond
Contract Renewal,"Health Progress, September-October 2001, pp. 41-42.
Copyright © 2003 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.