Ethics and Politics
Ethics and politics. You may be wondering what these two concepts have to do with each other. When I think about ethics, I think of words like good, wholesome, clean. When I think about politics, words that come to mind include deceptive, dishonest, dirty. However, these two concepts are very intertwined, especially when you focus on the policy part of politics.
Ethics guide the development of policies by helping define problems and development of solutions to problems (Longest, 2016). Ethics directly impact the outcomes and consequences of healthcare policies. Policy making, particularly health care policy making, should be guided by the four ethical principles of autonomy, justice, beneficence, and nonmaleficence because of the impact that the policies have on people’s lives (Longest, 2016). The key word here is “should.” Just because they should be the guiding principles, that does not always mean that this always the case.
When we look at the problem of access to oral health care for pregnant women without dental insurance as a public health policy problem, the ethical implications are vast. Public health as an entity is morally obligated to uphold the four ethical principles previously stated: doing the most good for the most people (beneficence), preventing harm (nonmaleficence), promoting health while upholding respect for persons (autonomy), and allocating resources to those who need them the most (equity and justice) (Abbasi et al., 2018). As a nurse, these are also the guiding principles of all of the care that I provide.
Justice
The ethical concept most relevant to this problem is that of justice, specifically social justice. Justice simply defined means fairness and can be viewed from many different perspectives:
- Distributive justice is creating fair access to health services so that all people can have the same opportunities for health and wellness (Longest, 2016).
- Similarly, social justice emphasizes equitable, or fair, access to resources, services, power, opportunities, and rights (Abbasi et al., 2018).
- The egalitarian perspective of justice is reflective of the concept of health equity. Everyone should have access to the health resources that they need and those who need more should get more (Longest, 2016).
Ethics in public health focus on these forms of justice by promoting universal health care, access to appropriate care for all individuals, and health care as a human right (Abbasi et al., 2018). Medicaid and Medicare, government funded health insurances, are a step towards this ideal in that that they provide more health care coverage and financial assistance for those who are poorer and need more help (Longest, 2016).
So if these are our guiding principles in health care and public health policy, then why doesn’t everyone have equitable access to care in the United States? Why don’t all pregnant women have access to dental care? Well, if you read my last blog, you would know that Arizona’s Medicaid does not cover preventative dental care for adults. Why don’t they cover it you ask? Your guess is as good as mine, but in our market economy, often financial interests rule.
Social Determinants of Health
We can’t talk about social justice and health equity without discussing social determinants of health. Social determinants of health (things like race, socioeconomic status [SES], health insurance, gender, age, environment, etc.) contribute to unequal access to oral health care. Those without private dental insurance lack the economic resources to obtain basic oral health care due to likely also having low SES (Lee & Divaris, 2014). This health disparity related to lack of access to care must be addressed by policymakers (Lee & Divaris, 2014). In order to reduce oral health disparities, it is also important to inform policymakers about how the other social determinants of health impact oral health, support health as a human right, and share the message that oral health is vitally important to overall health (Lee & Divaris, 2014). For the promotion of justice, public health policy must address the systems and the laws that perpetuate inequities (Abbasi et al., 2018).
After not passing last year, the bill for dental coverage for pregnant women under Medicaid is in legislation again. We need policymakers to approve this bill in order to increase access to care. Will passing this bill solve all of problems causing oral health disparities?
No. But it is a vital first step to eliminating a huge barrier.
I will leave you with this video, which offers a perspective on the sobering reality of the state of social justice and health disparities in our health care system.
(WilderBrathwaite, 2008)
“The simple truth is that disparity is caused by the economic and social policies of a nation that values its wealthier citizens at the expense of the poor and the middle class” (WilderBrathwaite, 2008).
References
Abbasi, M., Majdzadeh, R., Zali, A., Karimi, A., & Akrami, F. (2017). The evolution of public health ethics frameworks: Systematic review of moral values and norms in public health policy. Medicine Health Care and Philosophy, 21, 387-402. doi: 10.1007/s11019-017-9813-y
Lee, J. Y. & Divaris, K. (2014). The ethical imperative of addressing oral health disparities: A unifying framework. Journal of Dental Research, 93(3), 224-230. doi: 10.1177/0022034513511821
Longest, B.B. Jr. (2015). Health policymaking in the United States (6th ed.). Chicago, IL: Health Administration Press.
WilderBrathwaite, G. [Loyola Bioethics]. (2008, January 8). Social justice in health care [Video file]. Retrieved from https://www.youtube.com/watch?v=HPExmazIk5U
Oral Health Care Access for Pregnant Women: A Health Policy Blog 
Hello,
I think it is impossible to talk about health inequality without talking about the part racial discrimination plays in health accessibility within our community. Public health was established on the ethical motive of alleviating suffering and prolonging life. However, in these times of volatile healthcare policies, whether the cause of helping patients is worthy seems irrelevant to politics. Nevertheless, the changing policies of health care will change public health’s history. For example, preventable diseases are leading to boundless suffering and engulfing medical bills, which is crippling our society. The author of “Health equity and social justice: A health improvement tool” conducted a root cause analysis and concluded that community health risk is linked to social determinants of health conditions that shape an individual’s opportunity to adopt healthy behaviors and achieve good health¹. As a woman in childbearing age and a Nurse Practitioner student, I can benefit from gaining more knowledge about the various changes that occur in the oral cavity during pregnancy. These preventable oral cavities can lead to periodontal diseases such as periodontitis and gingivitis.
Access to safe communities where people can be active, have safe housing, nutritious foods, quality education, a good job with adequate wages, and affordable health care without discrimination, racism or bias is achievable. However, our country’s unconcealed discriminatory policies make it extremely difficult for minority and vulnerable groups to reach their optimal health. Even as the Patient Protection and Affordable Care Act (PPACA) expands access to previously uninsured Americans with the overall goal of universal health coverage, these inequalities remain¹. Regrettably, dental care is not an obligatory area for adults participating in the PPACA ². Thus to attain health equity for every individual, we need to acknowledge the enduring effects of American history and allow the knowledge to shape our interactions with disadvantage members of our society¹.
References
1. Benjamin, G. C. (2015). Health equity and social justice: A health improvement tool. Grant Makers in Health Views from the Field.
2. Hartnett, E., Haber, J., Krainovich-Miller, B., Bella, A., Vasilyeva, A., & Kessler, J. L. (2016). Oral health in pregnancy. Journal of Obstetric, Gynecologic & Neonatal Nursing, 45(4), 565-573. doi.org/10.1016/j.jogn.2016.04.005
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Thank you for your very insightful post about oral care in pregnancy and ethics. I was unaware of the law that did not pass in legislation last year. Having the access to the care is a big part of dental health. Dental health is difficult because patient who are on Medicaid do not get dental care covered. I have seen many patients have dental abscesses or poor dentition because of no dental insurance, but they are on state health insurance. Harnett, Haber, Krainovich-Miller, Bella, Vasilyeva, and Kessler (2016) suggest that any practitioners who care for women during pregnancy should become familiar with oral health competencies. I think that this recommendation is very helpful and could help to identify dental problems early on. Do you think that it would also help to make education about oral health and pregnancy more prominent? I remember when I was pregnant no one ever talked to me about oral health, including my OB. Luckily, I did go to the dentist while pregnant. But even with good health insurance and an education, no one ever reminded me during my pregnancy to continue to go to the dentist. That makes me wonder about those who don’t have the same education/ insurance and how they would know to maintain good oral health.
Hartnett, Haber, Krainovich-Miller, Bella, Vasilyeva, & Lange Kessler. (2016). Oral Health in Pregnancy. Journal of Obstetric, Gynecologic & Neonatal Nursing, 45(4), 565-573.
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