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Ethical Aspects Of Practice Deficits
Running Head: ETHICAL ASPECTS OF PRACTICE DEFICITS
Ethical Aspects of Practice Deficits in Breast Cancer Screening and Management in African
American Women
Pauline Thompson
Fall 2014
MPH 560
Dr S. Watkins-Bailey
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Ethical Aspects Of Practice Deficits
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Ethical Aspects of Practice Deficits in Breast Cancer Screening and Management in Minority
Women
The United States has made great strides in health care, preventative health, advanced
medical technology and treatments, management of chronic diseases facilitate healthy outcomes.
A 2011 report on healthcare disparities by the Agency for Healthcare Research and Quality
(AHRQ) states “our system of health care distributes services inefficiently and unevenly across
populations…These disparities may be due to differences in access to care, provider biases, poor
provider-patient communication, and poor health literacy” (p. 1). This is a troubling scenario for
the provisions to provide quality health care is at hand but obviously not utilized efficiently or
effectively. The focus on research, education of health personnel and multiple programs
developed for the provision of healthcare for all is a goal that has been achieved in some areas in
society but disparities remain for certain groups. A report titled “Unequal Treatment” by the
Institute of Medicine (IOM) evaluated the disparities in healthcare disclosed regardless of the
advancement in medicine, minorities continue to be underserved (Medley, Stitch & Nelson,
2003).What influences or promotes these disparities? The report previously mentioned by IOM
postulates:
the historical evolution of healthcare for persons of color, the current financial
and organizational structures of health systems, the settings in which care is
delivered, and the nature of the workforce providing care may, both
independently and jointly, influence the care that minorities receive (Medley,
Stith & Nelson, 2003, p. 80)
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The individuals that may contribute in this unfortunate but commonplace occurrence
include healthcare providers, case managers, health system administrators and even the patients
themselves.
Leonard and Harper (2010) also made reference to reasons for disparities in breast cancer
care, they stated these as “poverty, not enough funding for screening programs for the uninsured
and underinsured, cultural beliefs, practical barriers, geography, misconceptions and lack of
awareness, false sense of security, shortage of qualified care providers and quality screening
facilities”(p. 23-24). Disparities in the incidence of breast cancer has been addressed in a
multitude of studies, Breast cancer continues to be a devastating disease affecting women, it is
the second leading cause of death (lung cancer is the first), the National Cancer Institute (NCI),
Surveillance Epidemiology and End Results (SEER) fact sheet predicts “that 230,480 women
will be diagnosed with and 39,520 women will die of cancer of the breast in 2011” (2011). To
further elaborate; the incidence and rate of breast cancer between 2004-2008 reported 124.0 per
100,000 women were diagnosed with breast cancer of which 127.3 were white and 119.9 were
black (NCI, 2011). The death rate of breast cancer by race and ethnicity does not reflect the high
incidence in white women as previously mentioned; per 100,000 women, 22.8 were white
compared to 32.0 black reflecting a higher mortality rate for these women (NCI, 2011).
The cause of breast cancer remains unknown, there is no specific treatment instead there
is a multifaceted approach and research for breast cancer prevention and treatment continues to
develop. Risk factors have been speculated and could be categorized as those that cannot be
changed due to gender, age, genetic risk factors and lifestyle related factors e.g. nulliparous or
women who had their first child after age 30, oral contraceptive use, hormone replacement
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therapy. Other risk factors are mentioned in studies that are controversial, uncertain and
unproven i.e. antiperspirants, smoking, breast implants and underwire bras. The lifetime risk of a
woman born now developing breast cancer is calculated at 12.2% otherwise expressed as 1 in 8,
compare this to a lifetime risk of 1 in 10 during the 1970s (NCI,2010). Even though the
incidence of breast cancer has increased survival from breast cancer has reached an all time high,
this is probably because women are better informed, breast self exam is promoted, clinical breast
exams are routinely done by primary care physician or gynecologist, screening mammograms are
encouraged on a regular basis and treatment has improved. So, with these interventions why do
some women present with late stage breast cancer? One cannot blame the disease but the late
detection and fear of the disease provides the basis for advancement with severe consequences
i.e. extensive surgery, adjuvant therapy of chemotherapy and radiation or death. If breast cancer
is detected early then the rate of survival and treatment is optimal, the five year survival rate of a
localized tumor is 98.6% compared to 23.3% for a metastasized tumor (NCI, n.d.).
In 2011, the American Cancer Society’s (ACS) report on cancer in African American’s
hypothesized that African American women diagnosed with breast cancer have a poor prognosis
due to a “higher grade, distal stage, and negative hormone receptor status” and “appear to be at
particular risk for basal-like breast cancer (i.e., triple-negative cancers), an aggressive subtype of
breast cancer associated with shorter survival” (p. 8). From personal experience, the incidence of
breast cancer among African American women relates to the reports mentioned here, during my
employment at a breast center for newly diagnosed breast cancer or abnormal breast issues, 30 of
440 women were diagnosed with breast cancer of which 12 were African American. Diagnosis
of a stage 4, triple negative or metastatic cancer presented in half of these women; in comparison
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only two women out of the 30 were diagnosed with similar cancers. Also many of these women
were under the age of 40, Newman (2005) reported, “although breast cancer risk clearly
increases as a function of age, African-American women under the age of 45 years have a greater
incidence of breast cancer than Caucasian-American women in this young age range”.
It is
frustrating to see this happen, it is very difficult to witness a young single African American
woman present with late stage breast cancer that does not have a support system, has a poor
socioeconomic background and limited understanding in regards to her diagnosis. Questioning
these women as to why they waited so long revealed reluctance for treatment or surgery due to
loss of hair or disfigurement which they believe may lead to rejection from their peers, spouses
or significant other; it is unfortunate that outward appearances supersede one’s health outcome
and chance of survival. These young women present with a serious diagnosis that requires
immediate attention, but the first obstacle is to overcome the denial phase which is very common
and hinders the treatment planning. So, how do we prevent a young African American woman
present with late stage breast cancer? These women have the right to make their own health care
decision but to what cost?
Analysis of the ethical issues to address mammogram screening among this group reflects
on the ethical principles of autonomy, beneficence, non-maleficence, and justice. An individual
has the right to make their own health choice, this approach (autonomy) calls attention to
“liberty, privacy and informed consent of individual persons in the face of a health intervention
carried out by other parties” (Phau, 2013). The analysis of the community utilizes the assessment
core function and provides an insight into who is at risk and what resources are available to
educate health care providers and women, this information no doubt is important within the
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community setting for public health officials to identify and utilize interventions to reduce the
risk of breast cancer. Organizing outreach programs should focus on capturing African American
women in the community and educating them on the risks of breast cancer, these programs
should relate to their cultural and socioeconomic backgrounds. Providing this information
addresses informed consent and arms the individual with the knowledge to make an educated
choice. Outreach programs should emphasize the importance of participating in research trials;
Newman points out these should focus on genetic counseling, breast screening and treatment,
and chemoprevention trials (2005). This is not an easy process for one has to be attuned to the
health requirements and understanding of the culture and the racial disparities in healthcare.
There are obvious healthcare disparities, there is a need to improve access and find strategies to
reduce disparities. Data and research is necessary to address their unique needs, the problem is
how to encourage minority women to participate in programs and become aware of this disease
to promote health equity. The implementation of screening mammograms for women over the
age of 40 has brought about the detection of early stage breast cancer with favorable treatment
and survivorship outcome but the incidence of advanced stage breast cancer continues among
African American women (Newman, 2005).
A public health intervention is necessary to address the issue of an effective screening
mammogram program which is where the principle of beneficence (do good) should be apparent,
the benefits of screening tests in general are that early detection and early treatment improve
survival. Nickitas, Middaugh and Aries (2011) stated:
Public health providers must be aware of the needs of diverse groups and the
cultural influences on their health...health professionals must know how to assess
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health issues, including risks and influences, health behaviors, and the ways
culture shapes attitudes and practices (p. 35).
Involvement of the public health department is a way to bring about change in health policy at
the local level which eventually can permeate to the state and federal level, obviously healthcare
is provided locally and the impact of their services is an initial step of addressing the disparities.
The principle of non-maleficence is to do no harm. Consider the legacy of race related
health disparities and inappropriate treatment (e.g. Tuskegee experiment), for some African
Americans this continues to be a source of mistrust and hesitancy to seek healthcare. The issue
with mammography screening that these women may have heard off is the possibility of false
negative or false positive results which lead to further studies, biopsies and findings of noninvasive changes that may never progress to invasive cancer but nonetheless often result in
psychological burden, lumpectomies, radiation, and hormonal therapy. An article by Fowler
(2006), highlights the processes that African American women use to make decisions about
mammograms. Distrust and the negative effects of medical services for African Americans can
hinder public health intervention; in the article a young woman recapitulates these views in the
following statement:
Most of the tests that’s been done to check if mammograms are necessary haven’t
been done on Black women. Show me one report that says Black women don’t
die from getting all that X-ray put in you. These are the facts that I need. (Fowler,
2006).
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The importance of a culturally tailored approach can open doors to greater trust and
understanding, many African Americans are distrustful of any kind of governmental system
therefore it can be very challenging to establish a rapport but one needs to know what these
women are confronted with in their community.
The ethical principle of justice indicates that there should be fair treatment of individuals,
there ought to be equal or equitable benefit for all. These women face obstacles to healthcare
initiatives due to lack of health insurance, access to care, awareness of breast cancer risks and
screening methods and cultural differences. These barriers may explain the disparities of
mammogram screening in women from different race, culture and socioeconomic background.
Even though the promotion of screening programs into the community of there are still
underlying features that may hinder the success of the program, social injustices can lead to the
differences in outcomes. Lack of available and appropriate services and poor transportation to
services can contribute to the disparities. Ensuring women have access to mammogram screening
and clinical breast exams are preventative measures that have been addressed by the formation
of the National Breast and Cervical Cancer Early Detection Program, this provides women who
are uninsured, low income and of poor socioeconomic standards to have timely access to breast
and cervical cancer screening ( CDC, 2013b). This program is funded through Medicaid; in
2011, 334,300 women received screening mammogram and 5,781 were diagnosed with breast
cancer (CDC, 2013b).
Implementation of the Affordable Care Act will increase accessibility of
screening mammograms for many women due to the expanded health insurance coverage and the
development of Accountable Care Organizations. Clinical trials are important to gain
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information for prevention, screening, diagnosis, quality of life and genetics many women are
not notified or are too scared to participate due to lack of knowledge particularly minority
women.
The underlying aspect of social injustice is also apparent in the interaction of medical
personnel and minority women. Fowler, B.A. (2006), identified the importance of appropriate
physician-patient relationship and its reflection on a person’s health decision:
The negative attributes of male physicians had influenced their use of healthcare
services. The attributes, such as aloofness, arrogance, a hurried manner,
impatience, and cultural insensitivity, had a negative effect on how the women
interpreted information and encouraged women’s silence (p. 972).
There is a need to encourage minorities into the healthcare profession; the premise is that
cultural competence and reduction of cultural barriers are addressed with a better understanding
if presented by a minority healthcare provider which promotes and enables access to healthcare
(Nickitas, 2011). There are not many organizations specific to the African American woman but
Sisters Network, Inc provides extensive knowledge about breast health awareness, survivorship
and clinical trials information (Newman, 2005). The significance of a survivor advocate cannot
be underestimated because utilizing one can play a strategic role in breast health awareness.
Programs should be provided to educate about the signs and symptoms of breast cancer, breast
self exam and screening mammograms. There are two other important aspects of African
American culture that can be looked into for outreach programs ; it is evident that community
and church-based programs are important entities in African American lifestyle; therefore
Ethical Aspects Of Practice Deficits
programs interacting with these may be a plausible idea to encounter, educate and disseminate
information regarding breast health awareness.
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References
Agency for Healthcare Research and Quality (AHRQ) (2011). U.S. Department of Health and
Human Services. National Healthcare Quality Report 2010. AHRQ Publication No. 11
0004. Retrieved from http://www.ahrq.gov/qual/nhqr10/nhqr10.pdf
American Cancer Society (2011). Cancer Facts & Figures for African Americans 20112012.Atlanta: American Cancer Society. Retrieved from
http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/docum
ent/acspc-027765.pdf
Fowler, B. A. (2006). Claiming Health: Mammography Screening Decision Making of African
American Women. Oncology Nursing Forum, 33(5), 969-975. doi:10.1188/06.ONF.969975
Fowler, B. (2006). Social Processes Used by African American Women in Making Decisions
About Mammography Screening. Journal of Nursing Scholarship, 38(3), 247-254.
doi:10.1111/j.1547-5069.2006.00110.x
Leonard.D & Harper.L. (2010).The Impact of Diversity on Breast Cancer Care. Retrieved from
http://www.ghgmedia.com/webinar/handouts/092810__Diversity_Impact.pdf
National Cancer Institute (NCI). (2010). Probability of Breast Cancer in American Women.
National Cancer Institute Fact Sheet. Retrieved from
http://www.cancer.gov/cancertopics/factsheet/Detection/probability-breast-cancer
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National Cancer Institute (NCI). (n.d.).SEER Stat Fact Sheets: Breast Retrieved from
http://seer.cancer.gov/statfacts/html/breast.html#survival
Newman. (2005). Breast Cancer in African-American Women. The Oncologist. vol. 10 no. 1 114. doi:10.1634/theoncologist.10-1-1
Nickitas, D., Middaugh, D. & Aries, N. (2011). Policy and Politics for Nurses and Other Health
Professionals. Sudbury, MA: Jones and Bartlett
Phau, K. (2013). Ethical Dilemmas in Protecting Individual Rights Versus Public Protection in
the Case of Infectious Diseases. Infectious Diseases: Research and Treatment. 2013:6 15. doi: 10.4137/IDRT.S11205
Smedley, B., Stith, A. & Nelson, A. (2003). Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care. Institute of Medicine. Retrieved from
http://books.nap.edu/openbook.php?record_id=10260