Hidden in Plain Sight: Stigmatizing Language in Patient Medical Records

摘要 在我们的医疗体系中，患者并没有得到平等的对待。来自边缘种族/民族群体的人，年龄较大 成年人和健康素养低的个人，肥胖，镰状细胞疾病和物质使用障碍通常是 卫生专业人员的负面看法，对他们的医疗质量产生了不利影响。虽然很多人 造成这种差异的因素中，临床医生对患者的偏见是一个重要因素。最重要的是 家长研究的目标是改善对不受尊重和/或受尊重的人的护理质量和公平性 在医疗保健领域被污名化。家长研究的具体目标是：(1)建立污名化语言的分类学 在医疗记录中，(2)测量和测试这种语言的使用是否存在偏见，以及(3)减少这种语言的使用。中环 这个补充提案的前提是这种对病人的不尊重，以及由此产生的耻辱 出现在他们的医疗记录中的语言，是由一套不充分的生物伦理和专业人员推动的 未能完全描述临床医生必须尊重患者作为人的道德义务的规范。差不多了 半个世纪以来，波尚和奇尔德里斯一直主导着卫生专业人员的伦理教育 《生物医学伦理学原理》，1979年首次出版，现已出版第8版。波尚和奇尔德里斯 他们不赞同在道德上尊重所有患者的观点；他们写道，尊重自主的义务做到了 不延伸到…的人不成熟、无行为能力、无知、被胁迫、被剥削或类似的…毒品-- 依赖病人就是一个例子。我们的家长研究提供了一个独特的机会来全面探索 关于尊重人的原则的临床医生、病人和生物伦理学家的观点。我们的总体目标是提供 临床医生具有丰富的尊重患者作为指导临床实践的人的概念，由 那些被边缘化的人。我们的具体目标是(目标1)定性地探索道德信仰、价值观和 30例患者对不同类型污名化语言反应的尊重性质推理 在医疗记录中找到的。最有可能在医疗保健领域受到不尊重的患者将被过度抽样。(目标2) 定性地探讨30名临床医生关于尊重的本质的道德信念、价值观和推理。 对医疗记录中发现的不同类别的污名化语言的反应。临床医生将被挑选出来 最大限度地提高年龄、性别和专业的可变性，同时过度抽样那些在 医疗行业。(目标3)召集生物伦理学家专家小组审查患者和临床医生 在目标1和目标2中引出的观点，在其他相关文本的背景下，并应用反思框架 在形成尊重病人作为人的道德义务这一牢固概念的过程中保持平衡。这 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 可为未来的政策方向提供信息的生物伦理问题和生物伦理方面的能力建设)，并具体 解决生物伦理界存在的一种结构性种族主义，这种形式始终如一地 默默地破坏了我们减轻医疗保健不平等的努力。

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.