Chapter 10: What We Owe Our Patients

Upholding Our Ethical Obligations to Ensure Healthcare Equity for All Patients

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As physicians, we have taken an oath to do no harm. Yet in upholding a culture that excuses our lack of progress—let there be no mistake—we have done, and continue to do, harm.

The culture of medicine—through its willful ignorance—upholds the very institutions that perpetuate the inequities we are charged with dismantling.

The logical consequence of preserving this culture for its members is inequity for its patrons.

There will inevitably be the counterargument that medicine merely reflects broader social inequities. To which I say: it shouldn’t. We should be better. We must be better. In donning the long white coat, we swore we would be. We dedicated our lives to service, grounded in the aspirational belief that by improving health, we could help people live their best, most fulfilling lives. Our patients must hold us accountable to the promise of that mission.

The Hippocratic Oath isn’t just a historical artifact or ceremonial ritual—it’s a binding contract between physicians and society. When we pledge to “first, do no harm,” we aren’t just promising to avoid surgical errors or medication overdoses. We are committing to examine all the ways our actions and inactions cause suffering—and to systematically eliminate those harms wherever they appear.

Racial disparities in healthcare outcomes are among the most pervasive and deadly forms of medical harm in modern America. When Black mothers die at three to four times the rate of white mothers, when Black patients receive substandard pain control, when providers make decisions based on race rather than clinical evidence—we are violating our core ethical commitments.

These harms are not accidental. They are systematic and predictable. We can measure them, track them, and prevent them. That we do not do so consistently makes us complicit in the resulting suffering and death.

This complicity takes many forms. Sometimes it’s active—the provider who offers different treatments based on race, the nurse who responds differently to pain depending on skin color, the administrator who maintains policies that disadvantage entire populations.

More often, it’s passive—the silence when colleagues make racist remarks, the failure to question disparate outcomes, the shrug of “that’s just how things are” in response to evidence of inequitable care. Passive complicity may be even more dangerous because it is more common and harder to identify and address.

Medical ethics offers clear guidance. The principle of justice demands that we distribute benefits and burdens fairly, without regard to morally irrelevant traits like race or ethnicity. The principle of non-maleficence requires us to prevent harm, not merely avoid causing it directly. The principle of beneficence obligates us to promote patient welfare, which includes addressing systematic barriers to optimal care.

When healthcare institutions tolerate disparities, they violate all of these principles. They distribute care unequally, fail to prevent foreseeable harm, and prioritize institutional comfort over patient welfare.

These are not minor lapses—they are fundamental betrayals of the values that justify the public’s trust in medicine.

And that trust is not unconditional. It must be earned—through demonstrated competence, integrity, and accountability. It can be lost when communities come to believe, with good reason, that healthcare institutions do not serve them fairly or effectively. In many communities of color, that trust has already been deeply eroded by decades of discriminatory care and empty promises.

The consequences go far beyond individual patient encounters. When communities lose trust in healthcare institutions, they delay seeking care, avoid preventive services, and become less likely to follow treatment recommendations. These behaviors—rational responses to systemic failures—lead to worse health outcomes that are too often blamed on patients, not the institutions that failed them.

This creates a self-perpetuating cycle: discriminatory care leads to poorer outcomes, which feed stereotypes, which justify further bias. Breaking this cycle requires acknowledging healthcare’s role in creating and maintaining it.

The claim that medicine simply mirrors broader social inequalities is both false and morally irrelevant. False because healthcare institutions hold immense power to shape social outcomes through their policies, practices, and resource decisions. Morally irrelevant because our professional obligations do not vanish when they become difficult or inconvenient to uphold.

If anything, our privileged position in society—the trust we’re given, the resources we command, the life-and-death weight of our work—creates a greater responsibility to address inequality, not an excuse to ignore it. We cannot claim to heal communities while sustaining the very forces that make those communities sick.

This doesn’t mean healthcare providers are responsible for solving every social problem. But we are responsible for ensuring that our own systems do not contribute to those problems. We have an obligation to examine our practices, question our assumptions, and change our structures when they produce inequitable outcomes.

The implications are clear. Healthcare institutions must implement robust, accountable systems to measure, monitor, and correct disparities in care. Providers must undergo training in implicit bias and cultural competence that drives real behavior change—not just awareness. Policies and procedures must be evaluated for their differential impact and revised when necessary.

Most importantly, these changes must be systematic rather than voluntary, measured rather than assumed, and sustained rather than episodic. The same rigor we apply to other quality and safety issues must also be applied to equity.

This isn’t just about complying with external requirements or shielding ourselves from legal liability—though those are valid concerns. It’s about living up to the values we claim to hold. It’s about earning the trust that society places in us.

Every patient who walks through our doors has the right to expect that their race won’t determine the quality of care they receive. Every family has the right to believe their loved one’s life is valued as much as any other patient’s. Every community has the right to healthcare institutions that serve all people fairly and effectively.

These aren’t radical demands—they are baseline expectations of professional competence and ethical integrity. That we continue to fall short of them remains one of the great moral failures of modern medicine. But it is also one of our greatest opportunities for meaningful reform.

The patients we serve deserve more than good intentions and lofty ideals. They deserve healthcare systems that function equitably—for everyone, regardless of background or identity. Our professional duty, our ethical commitments, and our shared humanity all point to the same truth: achieving healthcare equity is not optional.

It’s the price of admission to calling ourselves healers.