You are considering shifting resources from maternal-child health programs to programs for more members of the community. If black-white ,
You are considering shifting resources from maternal-child health programs to programs for more members of the community. If black-white disparities in birth outcomes continue, but the overall health of the community improves, have you met your ethical obligations as a health department?
Is there something about infant mortality that makes it special in consideration of fairness? Do we need to think about what is fair in a different way because infants are involved?
Should the role of race and racism in infant mortality impact how we set priorities and allocate resources? Why or why not?
There are 3 choices suggested in this case study:
1. Maintain funding for maternal-child health care
2. Shift funding from maternal-child health care to programs that impact the health of the larger community
3. Involve the community in deciding what the priorities are and how resources should be allocated
What are the ethical dimensions of each option?
If the community gets involved, who should speak for the community?
Read this case study then answer above questions.
3.8 Case 4: Black-White Infant Mortality: Disparities,
Priorities, and Social Justice
Department of Bioethics and Humanities
University of Washington
Seattle , WA , USA
Susan D. Goold
Department of Internal Medicine and Department of Health Management
and Policy Center for Bioethics and Social Sciences in Medicine
University of Michigan
Ann Arbor , Michigan , USA
This case is presented for instructional purposes only. The ideas and opinions expressed
are the authors’ own. The case is not meant to refl ect the offi cial position, views, or
policies of the editors, the editors’ host institutions, or the authors’ host institutions.
Preterm births, the leading cause of infant mortality, are increasing annually worldwide
(World Health Organization 2012 ). The United State s shares company with Nigeria,
India, and Brazil among the top ten countri es with the highest numbers of preterm births
and ranks 31st among Organisation for Economic Co-operation and Development (OECD)
nations in infant mortality (OECD 2010 ). Within the United States, racial and ethnic
disparities in infant mortality remain entrenched and have increased (MacDorman and
Mathews 2009 ). U.S. health policy leaders have made the elimination of health disparities a top public health priority (Centers for Disease Control and Prevention 2011 ;
U.S. Department of Health and Human Services 2011 ). Infant mortality is an important
area of focus for eliminating disparities, both in its own right and because the rate of
infant mortality serves as an indicator of the nation’s health due to its association with
maternal health, social and economic conditions, racial discrimination, access to health
care, and public health practices (MacDorman and Mathews 2009 ).
During the twentieth century, U.S. infant mortality declined 93 % (MacDorman
2011 ). In 1900, about 100 infants died per 1000 live births. By 2000, that number
fell to 6.89. During the last half of the twentieth century, the rate of black infant
mortality dropped dramatically. In 1950, black infant mortality was 43.9 deaths per
1000 live births compared with 26.8 deaths per 1000 live births among whites
(Mechanic 2002 ). But by 1998 black infant mortality fell to 13.8 deaths per 1000
live births compared with 6.0 deaths per 1000 live births among whites. As these
numbers show, both groups made signifi cant absolute gains, with blacks gaining
more in absolute terms—a reduction of 30.1 for blacks and 20.8 for whites. Yet,
black infant mortality still remained about twice that of whites.
These disparities have persisted in the twenty-fi rst century. In 2006, non- Hispanic
black women experienced the highest rate of infant mortality, with 13.4 infant
deaths per 1000 live births, while non-Hispanic white women had a considerably
lower rate, with 5.6 infant deaths per 1000 live births. Citing a 2006 report from the
National Healthy Start Association, MacDorman and Mathews ( 2009 ) report that
programmatic efforts to reduce disparities in black-white infant mortality have had
some successes at local levels, but eliminating the disparities is diffi cult.
The U.S. Centers for Disease Control and Prevention and the U.S. Department of
Health and Human Services have prioritized both the elimination of health disparities and improvement in overall population health. These twin goals—one distributive, the other aggregative—are separate and sometimes confl ict (Anand 2004 ).
Increases in health disparities often accompany advances in aggregate gains in population health (Mechanic 2007 ). Although this case is specifi c to the United State s, the
dilemma is not. Data show that signifi cant progress on child mortality has been made
in many countries but that this overall success is often coupled with increased
inequalities between advantaged and disadvantaged groups (Chopra et al. 2012 ). In
China and India, for example, disparities in mortality persist between boys and girls
younger than 5 years, a function of entrenched gender discrimination (You et al.
2010 ). These examples raise challenging questions about how ethically to assess
such cases and set priorities for the allocation of scarce public health resources.
3.8.2 Case Description
You serve as the director for the local health department in a racially segregated
urban city in the Midwest with one of the greatest concentrations of African
Americans in the United States. The city has a long history of civil rights activism
that led to protests and marches that ultimately empowered and mobilized black
communities and organizations. Your health department has a history of prioritizing
maternal-child health and the elimination of black-white disparities in infant mortality in its programs, an investment of resources affi rmed by the city residents
through the department’s community outreach program and planning processes.
Chronic underfunding of public health, made worse by the economic downturn,
has resulted in drastic and unprecedented reductions in the public health budget. In
consultation with your staff and community board of health, you have raised the
possibility of redirecting resources from maternal-child health into other programs
based on a number of practical and ethical considerations. As with national statistics, the city has seen signifi cant declines in black infant mortality, even as blackwhite disparities remain. You note that although the maternal-child health programs
are cost-effective, their impact on reducing black-white disparities seems to have
stalled. Other programs appear to meet targets more consistently. To help support
these other programs, you note that allocating resources to more effective programs
provides more “health” per dollar, thus meeting the utilitarian demand to maximize
overall health, which many view as the primary goal of public health and health
policy (Powers and Faden 2006 ). In addition, although black-white disparities in
3 Resource Allocation and Priority Setting
infant mortality persist, blacks have made signifi cant gains, declining more than
whites in some decades. You note that remaining inequalities could be deemed ethically acceptable by some standard s of equity , such as the “maximin” principle .
Although this distributive principle is subject to interpretation (Van Parijs 2003 ), it
is generally understood to require that social and economic inequalities work to
benefi t society’s least advantaged groups. Thus, inequalities (even signifi cant ones)
are morally acceptable as long as the least advantaged have signifi cantly benefi ted
(Powers and Faden 2006 ).
The director of community outreach proposes that the health department not
make this decision unilaterally, but instead listen to community opinions on these
questions of priorities and fairness. He suggests that the health department collaborate with community partners to host a series of public forums. He insists that a
topic of such historic and contemporary concern to the community must be subject
to public deliberation. Despite having a history of supporting community discussions, you are concerned about the cost of community forums, noting that they will
drain resources from an already slim budget.
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