Discrimination is a social phenomenon, and, as such, it pervades all social institutions, be they political, financial, or even medical.[1] The effect of experiencing discrimination in medicine can influence relationships with physicians, procedures and treatments received in a medical context, allocation of money in medicine and leisure activities, and even a researcher’s syntax who is studying stigma and bias in clinical medicine.
The principles of respect for autonomy, and the respect for multiculturalism, emphasized in American clinical ethics contradicts this stigmatization and discrimination. Accepting a patient’s way of life and how she or he treat him- or herself logically follows these principles. Physicians must not discriminate against conditions of life that are contrary to their own values or scientifically correlated to further health risks. In order to uphold these principles, and to prevent further maleficence to patients through the effects of this discriminatory behavior, research must go beyond whether or not such discrimination occurs in clinical settings and address how to educate physicians and researchers about how their behavior can produce staggering effects in the lives of their patients.
Bombak, McPhail, and Ward have researched the stigma experienced in Canada by women considered obese who seek medical care during their pregnancies, and their article has an interesting effect on the discourse of stigmatization and discrimination. In the abstract of their paper, they establish a philosophical concept that later will construe a paternalism that would be detrimental to a physician-patient relationship. In essence, the authors feel that “moralizing,” or assigning a good or bad connotation to a risk associated with one’s state of being can produce a dichotomy between physician and patient, disrupting their relationship.[2] This line of thinking follows a relativism that coincides with ethical and philosophical theory. This relativism, as Jacques Derrida employs it in his philosophical discourse, opposes empiricism as an epistemology.[3] Their idea becomes even more interesting when one considers the first paragraph of the introduction, in which they define the researched stigma as “based in evidence” and maternal obesity as a phenomenon that “creates adverse outcomes.”[4] These two phrases are intrinsically empiricist, because they assume that their “evidence” brings certainty to the understanding of the “adverse outcomes”, which inherently moralizes a state of being that they said should be considered with a relativism that supports the principles of respect for autonomy and multiculturalism. In that sense, the text of their research appears paternalistic, in that it presumes that their interpretation is good or correct about that state of being.
In the body of the article, the authors discuss resulting experiences of pregnant women considered obese, in terms of “language,” “discourses of risk,” “refusal of care,” and “re-focussing of blame discourse from weight to other types of social marginality, such as race.”[5] These effects do more than influence the physician-patient relationship through affecting the patient’s access to healthcare and altering her understanding of herself. This could qualify as doing harm to the patient’s state of being, and therefore, maleficence is evident through the stigmatization of obesity in pregnant women.
In patients of mental illness in England, Evans-Lacko et al. find that reported discrimination in healthcare and in the patient’s community results in financial cost changes. In the introduction to their article, the authors state that “individuals with mental illness may avoid health services…and forego engaging in relationships or social activities as a way to prevent stigmatizing experiences.”[6] This is their hypothetical psychoanalysis to explain the behavior of sufferers of mental illness, and it is furthered in some part by their results. they find that there is a financial “specificity in terms of the domain in which discrimination was experienced.”[7] The increased costs correlate with where patients report experiencing stigmatization and discrimination. This is a manifestation of social maleficence since when discrimination occurs in clinical settings, the cost of care increases and becomes a social barrier to patients. It harms them by preventing them from seeking healthcare under financial constraints.
In this way, the principle of maleficence is connected to the principles of respect for autonomy and multiculturalism. Through the stigmatization of the patient’s state of being, the physician asserts their paternalism. To prevent further maleficence through discrimination, and advocate for the autonomy and multiculturalism of patients, research in this area must shift toward reducing the discrimination and stigmatization instead of “trying to determine whether discrimination truly occurred or not.” [8] One must, as Rhoads and Dohan do in their article, accept that discrimination is a phenomenon in clinical contexts and find the optimal methods of educating doctors in ways of how to reduce the stigmatization of their patients’ conditions.
[1] Rhoads, MD, MPH, Kim, and Daniel Dohan, PhD. “Knowing It When You See It: The Need for Continuing Innovation in Research on Healthcare Discrimination.” Journal of General Internal Medicine 30, no. 10 (2015): 1387–88. Web. 1 Nov. 2016. doi:10.1007/211606-015-3387-2.
[2] Bombak, Andrea E., Deborah McPhail, and Pamela Ward. “Reproducing Stigma: Interpreting ‘overweight’ and ‘obese’ Women’s Experiences of Weight-Based Discrimination in Reproductive Healthcare.” Social Science and Medicine, no. 166 (2016): 94. Web. 1 Nov. 2016. doi:http://dx.doi.org/10.1016/j.socscimed.2016.08.015.
[3] Derrida, Jacques. “Structure, Sign and Play in the Discourse of the Human Sciences.” In Critical Theory Since Plato, edited by Hazard Adams, Revised Ed., 1117–26. San Diego: Harcourt Brace Jovanovich College Publishers, 1992.
[4] Bombak, McPhail, and Ward, 94.
[5] Ibid.
[6] Ibid., 98-9.
[7] Evans-Lacko, S., and et al. “How Much Does Mental Health Discrimination Cost: Valuing Experienced Discrimination in Relation to Healthcare Costs and Community Participation.” Journal of Epidemiology and Psychiatric Sciences, no. 24 (2015): 423–34. Web. 1 Nov. 2016. doi:10.1017/S2045796014000377.
[8] Rhoads and Dohan, 1387.
