AMA Journal of Ethics^®

Abstract

Increasing focus on health equity is placing a spotlight on health professionals’ roles. Recent public health crises—the opioid epidemic, maternal mortality, and the COVID-19 pandemic—have renewed focus on racial and ethnic inequity and underscored that trust is foundational to public health and health professionalism. Organizational, system, and policy reform demand that professionalism be redefined in terms of its capacity to motivate equity in health professions education and clinical practice.

Redefining Professionalism

Each fall, new students across the United States are inducted into the healing professions. In medicine, during white coat ceremonies, inductees don their iconic white coats and pledge an oath to the profession and to care for the public. Recitation of the oath is a solemn rite of passage, a significant step in response to one’s calling, and an expression of one’s commitment to medicine often repeated at graduation, when newly minted physicians pledge a version of the Hippocratic Oath or the Declaration of Geneva¹ before colleagues, families, and friends. Written over 2500 years ago, the Hippocratic Oath is now often interpreted as binding physicians’ service to the patient before them during individual clinical encounters. But those encounters are now widely acknowledged as “downstream” from key “upstream” social and political determinants of patients’ health outcomes and community members’ health status.^2,3 Although duties to individual patients remain important, this myopic focus urgently needs to be broadened to include public health and health equity. As Noam Chomsky argued in 1967, “it is the responsibility of intellectuals to speak the truth and to expose lies.”⁴

Public Expectations

Two landmark reports issued by the National Academy of Medicine (formerly the Institute of Medicine), To Err is Human: Building a Safer Health System⁵ and Crossing the Quality Chasm: A New Health System for the 21st Century,⁶ have invigorated public expectations for transparency and accountability in health care and elevated awareness of inequity in health care service access, delivery, and quality according to race, ethnicity, and socioeconomic status. These reports laid the foundation for a growing body of research on health equity.

Since 2000, attention has increasingly turned to health systems’ and health professionals’ roles in inequitable health outcomes. For example, in the United States, Black women are roughly 3 times more likely to die of pregnancy or its complications than White women,⁷ and Black patients tend to negatively rate their interactions with clinicians who score high on measures of implicit racial bias.⁸ Prescriptions contributed to nearly 47 000 opioid overdose deaths in 2018,⁹ and prescription drug price gouging and surprise billing have led to growing public concern about health care commercialization. Finally, although the COVID-19 pandemic has been one of the greatest demonstrations of clinicians’ commitments to patients and public health, the pandemic has also exposed American inequity on an international stage.

Public and media attention to these crises has illuminated clinicians’ individual and collective roles in perpetuating health inequity. Inadequacy of public health infrastructure and capacity are certainly to blame, but clinicians must also own how they contribute to health inequity by tolerating or expressing bias in practice, lacking vigilance about pharmaceutical marketing¹⁰ influences on prescribing, and inattention to how their downstream interactions with patients are influenced by upstream nonclinical factors far beyond the scope of what can be remediated during a clinical encounter.

It is important that no single profession be solely responsible for motivating health equity. 

Perhaps partly due to clinicians’ roles in perpetuating inequity, public trust in health care professionals has eroded. A 2014 study noted that only 34% of Americans reported having great confidence in medical leaders in 2012, down from 73% in 1966.¹¹ A 2016 poll of US adults by Stat and Harvard found that 34% of Americans believed physicians who inappropriately prescribed opioids were mainly responsible for the problem of prescription painkiller abuse.¹² Erosion of trust undermines patient-clinician relationships, exacerbates clinician burnout, contributes to moral injuries incurred by working in unjust systems, and diminishes health care quality and communities’ health. In the face of these challenges, what should members of the public be able to expect of health professionals?

Health Equity in Professionalism

Sociologists characterize professions by their specialized knowledge and training, autonomy and self-regulation, service and relationship to a client or patient, distinctive code of ethics, status,^14,15 and fiduciary obligations to serve communities that support professionals’ education and training as well as to patients. Fiduciary obligations to communities are not often widely understood or recognized as professional obligations, however. Many know that professionalism prohibits cheating on an exam, violating privacy and confidentiality, and committing fraud. But new professionalism standards go beyond individual actions to embrace clinicians’ public roles. The Liaison Committee on Medical Education, for example, requires curricular “recognition of the impact of disparities” and “potential methods to eliminate health care disparities.”¹⁶ The Accreditation Council for Graduate Medical Education (ACGME) has specified professionalism subcompetencies, including respect for patient autonomy; “responsiveness to patient needs that supersedes self-interest” and recognizes diversity; and “accountability to patients, society, and the profession.”¹⁷ Specialty-specific ACGME requirements include training in health disparities and advocacy “for quality patient care and optimal patient care systems.”¹⁸ The American Board of Medical Specialties articulates medical professionals’ “three-part promise to acquire, maintain and advance” ethical values grounded in patients’ and public interests, “knowledge and technical skills,” and “interpersonal skills.”¹⁹

Equity in the public sphere. The National Academy’s reports suggest that quality improvement must be understood in terms of public interest—specifically, with intentional focus on equity. One recent study by the Pew Research Trust, for example, revealed that views about why Black patients have suffered disproportionately from COVID-19 vary by political party, race, and ethnicity, with Democratic and Black respondents being more likely to attribute Black Americans’ higher COVID-19 hospitalization rates to “circumstances beyond people’s control” than to “choices and lifestyle.”²⁰ This variation is significant from an ethics and professionalism standpoint because if people’s views are not informed by upstream political and social determinants’ of Black Americans’ greater disease burden, then they will miss the role played by inequity in the pandemic. Advocacy, leadership, and knowledge of health systems science and health policy are all key competencies that must be cultivated in clinicians to be prepared to meet their obligations to the public to eliminate inequity in health status and to promote access to health services.

Equity in the profession. A more diverse student body and workforce is also key to motivating equity and public health. Medical students with minoritized identities report more discrimination and mistreatment than White students.²¹ Black people make up over 13% of the US population,²² yet only 4.8% of US physicians are Black²³ while 32% of lower-paid health care workers are Black.²² Millions of essential health workers have continued to work during the pandemic, despite very low pay and compromised safety due to limited access to personal protective equipment.²⁴ In medicine, an enduring privilege of membership in the profession has been professional self-regulation; professionalism should now require physicians to draw on their social status and cultural authority to press for health care workforce diversity, inclusion, and equity.

Accountability to the public. Health professions schools should be required to consider how their programs, graduates, and faculty contribute to motivating health equity in organizations’ mission and governance, community programs and outreach, diversity and inclusion, training, and activism.²⁵ Regulators must clearly delineate equity-based accreditation standards to maintain programs’ accountability to members of the public they serve and equity-based criteria for individual clinicians to maintain state-issued licenses and credentials. It is also important that no single profession be solely responsible for motivating health equity. Since good health care requires cross-disciplinary teams of professionals, professionalism should be framed in terms of collegiality in executing common responsibilities to serve the public interest equitably.

What Now?

Although not always on the right side of history’s equity battles, the American Medical Association established a Center for Health Equity in 2019.²⁶ Health professions organizations must engage health equity on all fronts (eg, gun control, reproductive health rights, and racial violence) and implement policies that prioritize equity. The pledge attributed to Hippocrates to “lead my life and practice my art in uprightness and honor”²⁷ should be regarded by those who take it as a professional obligation to resist oppression and all sources of inequity that undermine public health and patients’ well-being. The vow attributed to Hippocrates—“That into whatsoever house I will enter: it shall be for the good of the sick to the utmost of my power”²⁷—should be regarded by those who take it as a professional obligation to draw upon the social status and cultural authority conferred by their profession to improve the material conditions (social determinants) of patients’ lives that undermine individual and community health status. Lastly, the final lines of the Hippocratic Oath state: “If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times.”²⁸ Upon achieving health justice, we might then reap satisfaction and good repute in the measure that Hippocrates sought.