WMJ 05 2011 - World Medical Association

NORWAY
Social Disparities
time a social gradient in the distribution
of health and disease is well documented;
there are dramatic differences in health between
the socially advantaged and disadvantaged
between and within any country
[1]. Should physicians take this fact into
account in their clinical practice and act affirmatively
to correct socioeconomic biases
Would this be possible whilst preserving
the ethos of avoiding unfair discrimination
in their professional work
WMA ethical
recommendations: A tension
Avoidance of unfair discrimination is stated
in the Physician’s Oath in the WMA Declaration
of Geneva as: “I will not permit
considerations of religion, nationality, race,
party politics or social standing to intervene
between my duty and my patient”. Adopted
just three months before the UN Declaration
of Human Rights, the Oath acknowledges
the equal worth of every human being;
every individual is morally entitled to equal
concern. The Oath does not, however, establish
any broader concern for social justice.
At the same time, the WMA recognizes
the challenges that social disparities in
health poses to the health care system. In
2009, the association adopted a Statement
on Inequalities in Health (quoted in Box
1). Although the major causes of health inequalities
lie outside health care, the WMA
insisted that within the health care system
physicians play a major role in health promotion
and disease prevention, and states
their responsibility “(t)o identify, treat and
reduce existing health inequality”. The
recommended list of physicians’ responsibilities
includes identification of social and
financial factors that impact on inequality,
advocating for equal access to health care,
and promotion of research and education
on social inequality.
The Physician’s Oath and the Statement on
Inequalities in Health can be seen to pull in
opposite directions. On the one hand, the
physician should not let social and economic
factors influence clinical judgments. On
the other hand, the physician should contribute
to a reduction in the unacceptable
social inequality in health – an inequality
that clearly correlates with social and economic
factors.
Empirical support for clarifying
the ethical regulation of
professional practice
Whether the different regulations are inconsistent
depends on their practical interpretations
and implications. Some empirical
evidence indicates a need for clarification of
how ‘unfair discrimination’ actually should
be interpreted in practice. A recent survey
of a representative sample of Norwegian
physicians found that 55% agreed that physicians
should contribute to reducing social
health inequalities in the population by
supplying extra help to patients of low socioeconomic
status [2]. On the other hand,
most of the responding physicians reported
‘never’ or ‘rarely’ to take social factors into
account in their clinical practice.
The need for clarification is also supported
by other empirical findings. Several studies
find that physicians, as everyone else, are
subject to unacknowledged influence from
social and cultural factors. Such influence
can e.g. be observed when physician and
patient are similar in socio-cultural aspects,
which makes it easier for the physician to
judge the patient’s situation and needs [3].
Other studies show that patients with higher
socioeconomic status have better access
to specialized care [4].
To explicitly ignore information about the
patient’s socioeconomic status in clinical
decision making as expressed in the Oath,
may lead to an unjustified unawareness
of the interplay between socioeconomic
factors and access to healthcare. Consequently,
physicians may end up enhancing
health disparities rather than reducing
them because of a lack of attention to the
ways socioeconomic factors work in favor
of the socioeconomically advantaged on
one side and against the disadvantaged on
the other.
A reasonable way to take nonmedical
factors into account
Hence, the open question is how the relevant
non-medical factors should be taken
into account at the point of individual care.
The need to underscore the importance of
avoiding irrelevant and/or unfair factors in
healthcare decisions is clear. The risk of an
unacceptable influence on healthcare decision
making from strong economic and/
or social interests is always present; as is
the risk that prejudice or political belief
leads to discrimination – unconsciously or
not. Therefore, ordinary medical fairness is
commonly interpreted as to allow no other
concerns than medical need to influence the
decision [5].
That medical need should be the only criterion
for priority to care is, however, not
as straightforward as it may look at first
sight. The reason for this is the close interplay
between socioeconomic status and
medical need. Any physician will know that
patients differ in their ability to utilize the
same medical regimen; some patients need
more information than others, some need
more follow up in order to comply, some
need financial support, etc. The differences
in ability to benefit from treatment are not
only due to medical factors, but are also
closely connected to factors in the social
and cultural settings of the individual. A
reasonable interpretation of what it means
to treat patients as moral equals by giving
them equal concern is that every patient
should have the same opportunity to benefit
from treatment. Consequently, a medical
need for healthcare must be understood according
to the patient’s individual biologi-
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