Equality vs. equity in a publicly funded healthcare system

By Andria Bianchi

Living in a publicly funded healthcare system may lead some providers and/or organizations to strive to achieve a system of complete equality when it comes to the implementation of services. The idea that we ought to treat all people in the same way irrespective of other factors that may be relevant to their identity (e.g. race, gender, ethnicity, sex, sexual orientation, culture, language, religion, disability, socioeconomic status, age, etc.) is prevalent; this is primarily what it means to treat people equally.

Using equality as a guiding principle is, in many ways, commendable and helpful. It is commendable in that it suggests that all individuals ought to have equal access to receive the same care in the same kind of way, which means that a citizen who is poorer than others should not be denied necessary care on that basis alone in a publicly funded context. A goal of equality can also be helpful in that it may guide organizations and/or clinicians to develop policies and processes to help mitigate factors which may unintentionally and unfairly influence the provision of care (e.g. being influenced by implicit biases that favour or neglect certain kinds of people). If multiple people require a particular resource that is widely available, then a principle of equality would suggest that (all things being equal) the individuals ought to be treated in the same way when it comes to receiving it.

Interestingly, one of the most significant challenges with using equality as a primary principle in healthcare, especially when it comes to developing specific processes and protocols, is the same thing that is also seen as a benefit; namely, that a principle of equality suggests that all people ought to be treated in the same way. Why might this pose a challenge from an ethics perspective? The reason was mentioned in the previous Hospital News ethics column, which said that it is often the case that equity is what matters when it comes to determining the most ethically defensible course of action—not equality.

Equity suggests that a person’s individual vulnerabilities and life circumstances are relevant to determining the most ethically defensible act. For example, suppose two patients, Jamie and Jordan, are admitted to the same hospital to receive the same type of cancer treatment by the same clinician. Jamie and Jordan share many similarities. They are both 65 years of age, they live in a large urban city, they speak fluent English, and they have lots of family support. Now, suppose that by virtue of their cancer diagnoses, Jamie and Jordan are eligible to enroll in a clinical trial for research purposes. Additionally, suppose that the clinical trial team always reserves 25 minutes to explain research-related information to eligible patients and to answer questions; they provide the same information in the same manner to all people in order to ensure that they are treated equally (i.e., a principle of equality is prioritized). While using a principle of equality to guide a research consent process in general may be apt, it may also pose challenges under certain circumstances. If, for instance, Jordan or Jamie is a Black male who lived during the time of the Tuskegee syphilis experiment, a person of indigenous descent who lived during the time of residential schools and “Indian hospitals” in Canada, a transgender person who has encountered significant discrimination and disrespect by healthcare providers, etc., then these experiences, backgrounds, and potential vulnerabilities will need to be taken into account during the consent process. Consequently, the consent process may take more time and resources.

To take another example, suppose a hospital unit has a strict policy to discharge patients as soon as they are clinically ready; no other considerations are ever taken into account. The justification for this policy is to ensure that all patients are treated equally. While this policy may be legally permissible and appropriate for many patients, a person’s vulnerabilities and backgrounds may also be relevant when it comes to contemplating what is ethically permissible and/or preferable for discharge planning purposes. Sometimes, a longer length of stay may be ethically defensible even if a person is clinically stable. For instance, if a patient with paraplegia lives in a non-accessible shelter system in a rural location with no family support, then it may be ethically permissible to prolong their stay until adequate supports can be put in place.

If every patient is treated equally, then some ethically relevant information may not be considered. Equality implies that all people should be treated as though they have the same backgrounds, life circumstances, and vulnerabilities, which is certainly not the case. Instead of prioritizing equality, treating people equitably may be more defensible from an ethics perspective. Equity requires altering our typical approaches to care in light of relevant patient information; this may involve taking more time to speak with someone, prolonging a person’s hospital stay, exploring alternative clinical options, etc. Ultimately, equity allows for different cases to be treated differently; equality does not.

Andria Bianchi, PhD is a Bioethicist at University Health Network.