Hidden in Plain Sight: Stigmatizing Language in Patient Medical Records

摘要 在我们的医疗系统中，患者没有得到平等对待。来自边缘化种族/族裔群体的人， 成年人和健康素养低、肥胖、镰状细胞病和物质使用障碍的个人往往 被卫生专业人员负面看待，对他们的医疗质量产生不利影响。虽然许多 在造成这种差异的原因中，临床医生对患者的偏见是一个重要因素。总体 家长研究的目标是提高不受尊重和/或 在医疗保健方面受到歧视。本研究的具体目标是：（1）建立一个污名化语言的分类系统 在医疗记录中，（2）测量和测试使用此类语言的偏见，以及（3）减少其使用。中央 这项补充建议的前提是，这种缺乏对病人的尊重，以及由此产生的污名化， 在他们的医疗记录中出现的语言，是由一套不充分的生物伦理和专业的促进， 没有充分描述临床医生必须尊重病人的道德义务的规范。近 半个世纪以来，卫生专业人员的伦理教育一直以Beauchamp和奇尔德里斯的伦理教育为主导 《生物医学伦理学原理》，1979年首次出版，现为第8版。波尚和奇尔德里斯是 他们不赞同尊重是道德上对所有病人的责任的观点;他们写道，“尊重自主权的义务确实 不适用于.不成熟、无行为能力、无知、被强迫、被剥削或类似的人.毒品- 依赖性病人就是例子。”我们的家长研究提供了一个独特的机会， 临床医生、病人和生物伦理学家对尊重人的原则的看法。我们的总体目标是提供 临床医生有丰富的概念，尊重病人作为人，可以指导临床实践， 那些被边缘化的人。我们的具体目标是（目的1）定性地探讨道德信仰，价值观， 30名患者对不同类别的侮辱性语言的尊重性质的推理 在医疗记录中发现的。最有可能在医疗保健中受到不尊重的患者将被过度采样。(AIM（二） 为了定性地探讨30名临床医生对尊重的本质的道德信仰、价值观和推理， 对医疗记录中不同类别的侮辱性语言的反应。将选择临床医生， 最大限度地提高年龄、性别和专业的可变性，同时对那些在以下方面代表性不足的人进行过度抽样： 卫生专业。(AIM 3）召集生物伦理学家专家小组，审查患者和临床医生 在其他相关文本的背景下，从目标1和2中引出的观点，并应用反思的框架， 在制定尊重病人作为人的道德义务的强有力概念方面取得平衡。这 一项补充伦理提案旨在解决NIH科学政策办公室的两个优先事项（研究 可能影响未来政策方向的生物伦理问题和生物伦理能力建设）， 解决了生物伦理学界存在的一种结构性种族主义， 默默地破坏了我们为减轻医疗保健不平等所做的努力。

ABSTRACT Patients are not treated equally in our healthcare system. Those from marginalized racial/ethnic groups, older adults, and individuals with low health literacy, obesity, sickle cell disease, and substance use disorders are often viewed negatively by health professionals in a way that adversely impacts their healthcare quality. While many contributors to such disparities, bias among clinicians toward patients is one important factor. The overarching goal of the parent study is to improve the quality and equity of care for persons who are disrespected and/or stigmatized in healthcare. The parent study specific aims are to (1) develop a taxonomy of stigmatizing language in medical records, (2) measure and test for bias in the use of such language, and (3) reduce its use. The central premise of this supplemental proposal is that this lack of respect for patients, and the resultant stigmatizing language that appears in their medical records, is facilitated by an insufficient set of bioethical and professional norms that fail to describe fully the moral obligation clinicians have to respect patients as persons. For nearly half century, the ethical education of health professionals has been dominated by Beauchamp and Childress's Principles of Biomedical Ethics, first published in 1979 and now on its 8th edition. Beauchamp and Childress do not endorse the view that respect is morally owed to all patients; they write, “Obligations to respect autonomy do not extend to persons who…are immature, incapacitated, ignorant, coerced, exploited, or the like… drug- dependent patients are examples.” Our parent study provides a unique opportunity to holistically explore clinician, patient, and bioethicist perspectives on the principle of respect for persons. Our overall goal is to provide clinicians with a rich conception of respect for patients as persons that can guide clinical practice, informed by those who are marginalized. Our specific aims are (AIM 1) To qualitatively explore the moral beliefs, values, and reasoning of 30 patients about the nature of respect in response to different categories of stigmatizing language found in medical records. Patients most at risk of being disrespected in healthcare will be oversampled. (AIM 2) To qualitatively explore the moral beliefs, values, and reasoning of 30 clinicians about the nature of respect in response to different categories of stigmatizing language found in medical records. Clinicians will be selected to maximize variability across age, gender, and specialty, while oversampling those who are underrepresented in the health professions. (AIM 3) To convene an expert panel of bioethicists to review the patient and clinician perspectives elicited in Aims 1 and 2, in the context of other related texts, and to apply the framework of reflective equilibrium in the formulation of a robust conception of the moral obligation to respect patients as persons. This supplemental ethics proposal aims to address both priorities of the NIH Office of Science Policy (research on bioethical issues that may inform future policy directions, and capacity-building in bioethics), and specifically addresses a form of structural racism that exists within the bioethics community, one which consistently and silently undermines our efforts to mitigate inequities in healthcare.