Center for Health Policy and Ethics, Creighton University Medical Center,
2500 California Plaza, Omaha, NE 68178
johnstone@creighton.edu , http://chpe.creighton.edu/people/profiles/stone.htm
Describe relations of ethics and
interactive social influences on health.
 Explain what social justice demands in
addressing health.
 Explain practical implications of ethics
for addressing elderly health disparities in
Deep South RCMAR.

Ecological causality/social determinants
 Equality of capability
 Respect, social justice, care, solidarity

SE: Socioeconomic
ENV: Environment
H: History
ED: Education
SS: Social status
G: Geography
CH: Childhood
SE
CH
ENV
GEO
H
SS
Geiger 2006
ED

Sen, Amartya. The Idea of Justice. Harvard
Univ. Press, 2009
A primary objective of social justice
should be to provide everyone with the
means of and opportunity for equality of
capability.
 Capability: What people can actually
do and be.

Sen 2009

Powers, Madison; Faden, Ruth. Social
Justice: The Moral Foundations of Public
Health and Health Policy. New York: Oxford
Univ. Press, 2006.

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Health
Personal security
Reasoning
Respect
Attachment
Self-determination
Powers & Faden 2006

Sufficient
Collaboration & Partnering
Health
Selfdetermination
Personal
security
Attachment
Reasoning
Respect
Powers & Faden
(Dimensions)
Ethics
Well-being
Dimensions
•Health
•Personal security
•Reasoning
•Respect
•Attachment
•Self-determination
Powers & Faden
(Dimensions)
Social Determinants of
Health
•Income/wealth
•Physical environment
•Social environment
•Healthcare acc/qual
•Historical narratives

“Health promotion interventions take
place in a complex environment that
includes family and social relationships,
economic and geographic factors, and
physical barriers and opportunities, all of
which influence older persons’ ability to
process health information and translate
it into new behavior.”
NRC 2004, p.115

“There is increasing evidence that wellbeing in advanced age is as much if not
more a function of social connection
and respect then of access to medical
technology.”
Powers & Faden 2006, pp. 164-5

Remediate “systematic disadvantage”
that reduces length and health-related
quality of life
› Identify
› Prioritize responses
› Act
› Avoid/change policy that  disadvantage
Powers & Faden 2006, pp 87,99
Respect
Social
Justice
Respect
Care
Social
Justice
Respect
Social
Justice
Solidarity
Care
Healthcare institutions: Quality
assessments by R/E that are sorted by
age
 Local services: Assessments of access
and services by R/E that are correlated
with age

Policy advocacy and drafting
 Collaborative community partnerships

› CBPR
› Translation/intervention
Inter-/trans-disciplinary
 Institutional (structural/cultural criticism)
 Multiculturalism (including race, ethnicity,
“culture,” language): cuts vertically
(historically) & horizontally (now)


“There is no settled and accepted set of
principles for addressing causal questions
within the social sciences and different
disciplines have different levels of
tolerance for various kinds of
assumptions.” (IOM 37)
› What decision processes?
› How do cultural issues influence process and
outcomes?

Ethics of collaboration & partnering
› Community, academy, agencies, other orgs
 Research
 Intervention
 Policy
› Among disciplines
› Discipline groups and communities

Some resources: Baldwin et al. 2009,
Israel et al. 1998, Stone & Dula 2008,
Wallwork 2008
Easier: enhancing screening
 Harder: socioeconomic issues

Partridge & Fouad 2010

Should a special ethics be developed?
› Representation
› Intergenerational trauma
› Intergenerational cultural differences
› Communication
› Advocacy
› Concept of analysis
Postmodern, postcolonial, critical theory
 Assume hidden means of domination,
power, marginalization






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Attitudes
Structures (institutional, processes)
Language
Grant proposal design
Biomedical & public health models
Community and state services or agencies
Collaboration/partnering & community
 Special issues

›
›
›
›
›
›
›
›
›
Chronic care
Chronic disease/debility
Continuity & coordination
Transportation
Advocacy
Navigators, helpers, age-bridgers
Abuse
Life-course traumas
Relationships/connectedness

Attributes/knowledge/attitudes
 History/narratives
 Knowledge
 Connection
 Identification
 Modes of showing respect
 Age bias
1.
2.
3.
4.
5.
6.
7.
Mentoring
Workforce diversity
Older AA recruitment
Support enduring
research or new
directions
Better methods/tools
Increase scientific
knowledge to reduce
health disparities
Disseminate
*Tervalon & Murray-Garcia 1998
**Wear 2003
1.
2.
3.
4.
5.
6.
7.
Collaboration, cultural
humility*, deliberation,
iteration
Advocacy, insurgent
multiculturalism**
Respect, care, solidarity
Structural critique & reform
Insurgent multiculturalism**
Inclusive collaboration,
community knowledge &
priorities
Community knowledge &
priorities, local/regional
needs
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Baldwin JA, Johnson JL, Benally CC. Building partnerships between
indigenous communities and universities: Lessons learned in HIV/AIDS
and substance abuse prevention research. Am J Public Health.
2009; 99 Suppl 1:S77-82.
Geiger HJ. Health Disparities. What do we know? What do we need
to know? What should we do? In: Schulz AJ, Mullings L (eds).
Gender, Race, Class, & Health: Intersectional Approaches. San
Francisco: Jossey-Bass, 2006:261-288.
Israel BA, Schulz AJ, Parker EA, Becker AB. Review of communitybased research: Assessing partnership approaches to improve
public health. Annu Rev Public Health. 1998; 19:173-202.
NRC: National Research Council. (2004). Understanding Racial and
Ethnic Differences in Health in Late Life: A Research Agenda. Panel
on Race, Ethnicity, and Health in Later Life. Roldolfo A. Bulatao and
Norman B. Anderson, eds. Committee on Population, Division of
Behavioral and Social Sciences and Education. Washington, DC:
The National Academies. (Accessed April 27, 2010)
http://books.nap.edu/openbook.php?record_id=11036&page=R2
Partridge E, Fouad M. Community-driven approaches for reducing
health disparities in cancer. JAMA. 2010; 303(11):1090-1091.
Powers, Madison; Faden, Ruth. Social Justice: The Moral Foundations
of Public Health and Health Policy. New York: Oxford Univ. Press,
2006.




Powers, Madison; Faden, Ruth. Social Justice: The Moral
Foundations of Public Health and Health Policy. New York:
Oxford Univ. Press, 2006.
Sen, Amartya. The Idea of Justice. Harvard Univ. Press, 2009.
Stone JR and Dula A. “Race/Ethnicity, Trust, and Health
Disparities: Trustworthiness, Ethics, and Action.” In Cultural
Proficiency in Addressing Health Disparities. Kosoko-Lasaki S,
Cook CT, O'Brien RL. (Eds.) Sudbury, MA: Jones & Bartlett,
2008, pp. 37-56.
Wallwork E. Ethical analysis of research partnerships with
communities. Kennedy Inst Ethics J. 2008; 18(1):57-85.
Tervalon M, Murray-Garcia J. Cultural humility versus cultural
competence: A critical distinction in defining physician training
outcomes in multiculural education. J of Health Care for the
Poor and Underserved. 1998; 9(2):117-125.
 Wear D. Insurgent multiculturalism: Rethinking how and why we
teach culture in medical education. Academic Medicine. 2003;
78(6):549-554.
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