There is a rarely noticed tension between evidence-based medicine and some of our most popular concepts for how to address racial and ethnic healthcare disparities. Can we be evidence-based and also culturally competent and patient-centered?
A few ethicists have been thinking about this trade-off for some time, but recently it's been getting mainstream attention.[1]
Here's the problem: Disparities arise, in part, when clinicians don't understand the unique health values and beliefs of individuals from other cultures, races, or ethnic backgrounds.[2] So disparities should diminish with more artful, more patient-centered care – care that is specifically tailored to each individual's personal beliefs, values, and priorities.[3]
But evidence-based medicine doesn't urge the artful tailoring of care, and tailoring care to individual beliefs, especially if they are based on mistrust of healthcare, could actually worsen health outcomes for minorities.
David Sacket – one of evidence-based medicine's best proponents – once famously said that, when it comes to medicine, “Art kills.[4]” Of course, he was talking about physicians calling their individual bad habits “art.” But if physicians shouldn't use art as an excuse to deliver inappropriate care, should we be encouraging them to tailor care to each patient's requests, regardless whether these requests are evidence-based? Is the customer always right?
What should we do with cultural beliefs that might be harmful to health?
A certain convergence between cultural competence and evidence-based medicine is occurring. Cultural competence has moved away from teaching about population characteristics – which is otherwise known as stereotyping – and towards the notion of patient-centered care.[5] Evidence-based medicine, notorious for being derived from population data, is also trending towards patient centeredness as a core value to be promoted.[1]
But the ethical question remains: Would proponents of cultural competence, on the one hand, or evidence-based medicine, on the other, be willing to get worse outcomes, or spend more, if that were the result of some patient-centered decisions?
Patient-centered care is an important movement, and one we should encourage. But it won't come without raising some interesting ethical dilemmas.
That's my opinion. I'm Dr. Matt Wynia, Director of the Institute for Ethics at the American Medical Association.
The views presented are those of the author and should in no way be construed as policies of the American Medical Association.
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References
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