Healthcare Inequalities in the
Elderly: Ethics and Quality
Improvement
John R. Stone, MD, PhD
Center for Health Policy and Ethics
Creighton University Medical Center
Conflicts of Interest
• None known
Learning Objectives
• Explain evidence & racial/ethnic issues
• Describe an ethical framework
• Explain implications
Case 1: CML
• Probability of being offered full spectrum of
effective drugs
– @ 75 versus @ 50
Stone 2012, Cambridge Quarterly of Healthcare Ethics
Case 2: In Rehab
• 80, depressed or sometimes irritable
• Rehabilitation professional
– Regard as positive as at 45?
Stone 2012, Cambridge Quarterly of Healthcare Ethics
Case 3: 65 Breast Ca_AA Woman
• Excisional biopsy
• Breast tissue conservation
• Radiotherapy
– Same % advice as if White?
Stone 2012, Cambridge Quarterly of Healthcare Ethics
Case 4: Rheumatology
• “Aggressive” and “effective” care
• Same for older as for younger patients?
Stone 2012, Cambridge Quarterly of Healthcare Ethics
Case 5-Chronic Disease
• At age 72, will treatment be as established by
research as at age 50?
Stone 2012, Cambridge Quarterly of Healthcare Ethics
Case 6: Institutional
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Excellent tertiary hospital
Rigorous Quality Improvement (QI)
QI includes age-related care?
QI includes care per race/ethnicity?
Stone 2012, Cambridge Quarterly of Healthcare Ethics
Evidence Status
• Need more studies
• Existing data and care quality
– Bad to be elderly
– Worse to be elderly + racial/ethnic minority
• Uncertain
– (Probably) worse: elderly, racial/ethnic minority,
poor
Withholding Care & Ethics
• Fair distribution among age groups
• Unfair: merely because a person is old
– Christine Cassel: illegitimate “implicit rationing”
Cassel 2005
If you’ve seen one 70 year-old…
• “No ailment should ever be written off as an
"old age" ailment. Treating patients based on
their age means you can miss very significant,
treatable situations. …If you've seen one 70year-old, you've seen one 70-year-old.
Mark Lachs 2010
• “Every patient is different, and I hate the way
the health care system pigeonholes people
based on a number, and it becomes more
absurd as patients get to be 70, 80 and 90,
with great variations in their functional
ability.”
Mark Lachs 2010
Elderly Ageism
• Bias, prejudice, discrimination, devaluation
• Negative attitudes, stereotypes: dependent,
grumpy, lonely, rude, stubborn, socially
inactive, frail noncontributors*
• Mistaken beliefs: asexual
*Eymard & Douglas 2012
Causes: Elderly healthcare disparities
• Elderly ageism
• Education/training deficit
– Knowledge
– Skllls
• Insufficient Research
• Inadequate review
Causes: Elderly R/E Health Disparities
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Stereotypes
Bias
Discrimination
Personal level
Institutional level
Policy level?
Moral Framework
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Respect for persons
Justice
Beneficence
Nonmaleficence/do-no-harm
Care
Solidarity
Ethical Framework/Anchors
Respect
for
Persons
Solidarity
Justice
Beneficence
Do-no-harm
Care
Respect for Persons
Not just respect for autonomy
Empower
Respect
Listen
Humility
Engage
Culture
bridging
for
Persons
Recognize
Justice
• Fair application of respect for persons and
other professional ethical values
– Health/healthcare equity
• Remediation if unjust inequality or inequitable
treatment
Beneficence/Nonmaleficence
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Advance the patients’ good
Do no harm when avoidable
Minimize harm
In light of respect for persons and justice
Care
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Needs of particular others/personal
Empathic/emotional connection
Thoughtfulness/considerateness
Focus on vulnerable/dependent
Attention to quality/groups
Stone 2012, Cambridge Quarterly of Healthcare Ethics
Solidarity
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Alignment/unity/fellowship
Empathic bridging across distance
Opposes them/us
Focus: most disadvantaged
Stone 2012, Cambridge Quarterly of Healthcare Ethics
Foci of Equal Quality
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Patients you see
Institution
System
State/nation
Quality
Intent
Outcome
Race/Ethnicity Example
• “I treat everyone equally.”
• “I do not vary treatment quality with people’s
race/ethnicity and so forth, but I attune to
their individual needs.”
• “My system/institution does not do quality
assessments regarding race/ethnicity or age
group.”
Quality Improvement
QI
Outcome
Indicator
Assessment
Remediation
Reassessment
Quality Improvement
• Age
• Race/ethnicity
• Other
– Language
– Gender
– Socioeconomic status
Quality Improvement/Elderly & R/E*
Departments
Institution
Evidence
Ethical
Framework
Community
*Disparities Solutions Center.
Outcomes
Recommendations
Improving Attitudes & Views
• Enhanced curricular content
• Simulations: “The Aging Game” and others
• Narrative reflection
*Eymard & Douglas 2012
Recommendations: Direct Care Sites
• Open group inquiry/discussion
• Iterative group value assertion
• MMM: Mindful Mentoring & Modeling
Recommendations
• Individual clinician
– Communicate, engage, connect, honor,
empower
– Care, empathize
– Bridge cultural and age divides
– Reflect (respect, justice, care, solidarity)
Recommendations
• Individual clinician
–Mentor/model
–Narrative reflection
–Humility/self-critique
Recommendations
• Department/Division
–Curricular content
–Faculty development
–Value clarification
–Legitimize discussion
Recommendations
• Department/Division
–Mentor/model
–Promote QI
–Promote elderly research
Recommendations
• Institution
–Quality improvement
–Community involvement
–Department/Division inclusion
–Elderly research
Higher Levels
•Policy review
References
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Cassel CK. (2005) Medicare Matters: What Geriatric Medicine Can Teach American
Health Care. Berkeley: University of California Press.
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Disparities Solutions Center. Massachusetts General Hospital. Boston. (See several
documents regarding healthcare disparities.)
http://www2.massgeneral.org/disparitiessolutions/resources.html#imqual
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Eymard, A. S., & Douglas, D. H. (2012). Ageism among health care providers and
interventions to improve their attitudes toward older adults: An integrative review.
Journal of Gerontological Nursing, 38(5), 26-35.
Mark Lachs 2010: “Ageism in Medicine: How It Appears, Why It Can Hurt You: Interview
with gerontologist Mark Lachs.” Maureen Mackey. AARP Bulletin. November 18, 2010.
http://www.aarp.org/entertainment/books/info-112010/author_speaks_ageism_in_medicine.html (04Aug2012)
Powers, Madison; Faden, Ruth. (2006) Social Justice: The Moral Foundations of Public
Health and Health Policy. New York: Oxford Univ. Press.
Stone JR. (2012). Elderly & Older Racial/Ethnic Minority Healthcare Inequalities: Care,
Solidarity, and Action. Cambridge Quarterly of Healthcare Ethics. 21(3), 342-352.
Stone, JR. (2012) Healthcare Inequalities in the Elderly. Ethical Times. Bulletin of the
Program in Medicine & Human Values. California Pacific Medical Center. Sutter Health.
29(Spring), 1, 4-5.
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