(NewsNation) — Researchers studying clinical ethics consultations (CECs) at a Seattle pediatrics hospital found those consults were requested at a disproportionate rate for patients based on race and insurance coverage — which could either reveal bias among pediatricians or a greater need among minority populations.
The lead author Aleksandra Olszewski and her colleagues found Black patients were more than twice as likely to get a consult as white patients. Additionally, people with public or no insurance were almost twice as likely to get a consult as patients with private coverage.
These consultations can be requested by both providers and the families of patients. They’re used to inform providers how to ethically navigate care plans.
“A relatively common one in pediatrics is if teenagers with eating disorders and/or family members with eating disorders might disagree about treatments and clinical teams might reach out to ethics to help determine whether they can or should take over decision-making for a patient like that,” Olszewski said.
While anyone can request them, Ann Heesters, an ethics director at University Health Network in Toronto, said the reality is hospital staff are much more likely to start a CEC than patients’ families are.
“(Families) may not even know we exist,” she said.
A spokesperson for Seattle Children’s Hospital — where the study took place — emphasized the diverse work the institution does to “dismantle barriers to accessing care.”
“Participating in and supporting research studies like this is a component of the work taking place and provides necessary knowledge and insights into potential barriers to address issues and incorporate equity and anti-racism into all ethical decision making,” a spokesperson said in a statement.
Olszewski noted this research doesn’t necessarily prove these disparities exist in other hospitals as well but she has heard of similar disparities elsewhere.
“When I’ve presented this work to people from other institutions, anecdotally they agree with these trends too,” she said.
Heesters praised Olszewski’s paper for shining a spotlight on disparities in CECs, calling it a “gift to our field,” pointing out possible cultural conflicts that may be leading to a higher number of CECs.
“Health care providers contain all the prejudicial attitudes that exist in our society and they may unintentionally want the ethicist to come and say this family is too demanding or their values are not our values so we should just not give them a fair hearing,” Heesters said. “I don’t think they deliberately do that, but it may be the case that they see a family as more problematic if they have cultural practices that don’t align with their own.”
Olszewski said that one reason there may be more ethical consults among these patients is that they face more ethical dilemmas; Black and low-income patients are more likely to suffer from more serious health problems.
But Olszewski said another reason for the disparity may be due to racial bias.
“For example, you (compare) a white family with a patient who is considering brain death exam testing and a Black family who is, and the decision to call an ethics consult might be managed differently based on clinical team bias, clinical team racism, other -isms affecting their decision to actually call a consultant,” she said.
Heesters said cases involving minority and uninsured populations disproportionately getting ethics consultations is not necessarily a problem because they are designed to help patients.
“If patients come to us with more complex health conditions, or with low trust in healthcare, owing to background conditions that include experience with racism we should be prepared to spend the time required to understand their perspectives and help them and their healthcare providers achieve the outcomes that are right for them,” she said.
However, she did describe a couple of different scenarios where disproportionately assigning CECs for minorities could be problematic.
“A high number of referrals of cases involving marginalized populations is only a problem if people understand CEC as a mechanism for containing costs — for example, by hastening discharge or by limiting care — or for uncritically imposing the perspective of the clinical team on so-called ‘challenging patients,'” Heesters said.
Olszewski emphasized how the ethical consultation is done is important.
“If consults are called more often for some families due to bias, and ethicists listen only to the clinical team’s perspective and don’t consider bias or injustice in their analysis systematically, they could contribute to the harms of bias on certain families,” she said.
For now, Olszewski suggests the field should think more critically about these issues and consider “training around cultural competency, around bias recognition, around conflict management.”
