Teaching Justice in Health Care

“I will keep them [the sick] from harm and injustice. … Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves. …” —Hippocratic Oath, 400 B.C.

This well-known pledge, the foundation of medical ethics, is repeated in one form or another by graduating medical students as they take on the sacred privilege of caring for others. Out of it flows the ethical injunctions of beneficence, nonmaleficence, and justice. As a graduating physician, I did not fully comprehend the sophistication of this age-old oath. It was easy enough to understand that the goal of treatment was to make patients better and cause no harm. But what exactly is “justice” in the field of medicine? Some have understood it to mean equitable distribution of available resources while providing care for our patients. Or being just or fair in the treatment of patients.

Physicians are quick to state that their actions in therapeutic contexts are in the best interest of their patients, and they try their best to avoid harm. Physicians cannot, however, lay the same claim to justice. African Americans and other people of color have often borne the brunt of unjust physician practices. The COVID-19 pandemic exposed what has historically been the experience of people of color—that is, White patients are prioritized over Black patients. There were reports that Black patients did not have widespread access to COVID tests and were passed over for being placed on a ventilator or an EMCO despite having similar clinical presentations. In psychiatry, Black patients are more likely to be diagnosed with a psychotic illness even when the symptoms suggest otherwise, given intramuscular antipsychotic medications, and mechanically restrained, to mention only a few inequities, than their White peers.

The public and gruesome killing of George Floyd and subsequent global protests led to a long-delayed awakening. Suddenly physician groups began to profess an awareness of the inherent injustice of the U.S. health care system and of their historical maltreatment of their non-White physician colleagues. Dr. Jeffrey Geller, former president of APA, convened the Task Force on Structural Racism Throughout Psychiatry to study the issue in depth, educate the public, and make amends. The APA Ethics Committee gave an opinion thus: “To provide competent care, a psychiatrist should cultivate an awareness of the adverse effects on mental health that result from racism and ethnoracial discrimination. … A treating psychiatrist should be mindful of the impact that racism and ethnoracial and other kinds of discrimination may have in the lives of patients and their families, in clinical encounters, and in the development of mental health services. ...”

Despite the apparent awakening, psychiatry residents’ training on social (health care) justice remains sorely lacking. Concerned by this reality in their residency programs, several APA/APAF fellows took on the challenge and, under the auspices of the task force’s Workgroup on Fellow Projects and Leadership, created “A Primer of Online Resources on Structural Racism in Psychiatry for Medical Students & Trainees in Psychiatry.”

The effort to educate our residents will flounder without sustained attention at developing a formal and structured educational process in residency programs. Equal attention should be placed on training faculty, not just faculty of color, to teach this material. Combating injustice in our health care system requires all hands to be on deck. Future physicians and psychiatrists—and their patients—deserve no less. We should hold ourselves accountable to all the elements of our code of ethics: beneficence, nonmaleficence, autonomy (respect for persons), and, yes, justice. ■

Charles C. Dike, M.D., M.P.H., is chair of the APA Ethics Committee and former chair of the Ethics Committee of the American Academy of Psychiatry and the Law. He is also an associate professor of psychiatry and co-director of the Law and Psychiatry Division at the Yale University School of Medicine.