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In 1976, the legal ruling of the case Estelle v Gamble established the precedence of evaluating unjust healthcare practices and violation of Eight Amendment rights to prisoners with application of a test of deliberate indifference. Since this ruling, many more cases have emerged which present the complexity in application of the deliberate indifference test involving incarcerated pregnant women specifically. The practice of mass incarceration within this country has contributed greatly to the number of women and pregnant women incarcerated, without the necessary advancements or even establishment of healthcare standards within prisons to provide necessary care. Shackling of pregnant incarcerated in the course of their pregnancy and the practice of separating mother and child immediately at birth evidence the continuation of unacceptable practices occurring in the United States of America. To understand this topic and the issues involved, an understanding must be gained of the history, legal course, and healthcare practices faced by pregnant women and mothers who are incarcerated. / Urban Bioethics

Organ transplantation has the potential to improve and prolong the lives of many chronically ill people. However, organs are a scarce resource and a commodity to which not everyone has equal access. Equity issues are particularly evident amongst African Americans concerning kidney donation and transplantation. In this paper, I discuss the history of kidney transplantation and the disparities that exist in the African American community for both organ donation and transplantation. I explain how the organ allocation system has structural barriers that do not account for the social determinants of health. Then I explore the significant barrier of African Americans’ mistrust of the health care system and its role in kidney donation and transplantation. I use the principles of urban bioethics to discuss possible solutions to mistrust including community engagement, diversifying the physician work force, and concepts that move beyond cultural competency to cultural humility and structural competency. / Urban Bioethics

As a healthcare provider focused on women’s health, injustice is something that I see in my patients’ experiences daily. The reasons behind the injustice go far beyond the walls of the hospital. They are related to provider awareness and training, patient access and cultural ideals, as well as structural bias against women, specifically non-English speaking women and women of color. They exist in an entangled web, in which the compilation of multiple factors results in further bias and further distance between the actual care the patient is in need of and the care they receive. My planned future role is to be a provider in Urogynecology, and I will be starting my fellowship in July 2024. This field has a unique lens into the care of women, spanning all ages, races, ethnicities, and education levels. So many women experience incontinence and prolapse, yet so few get help and present to care. Often in the literature, there is documentation that Black and Brown women do not have these issues as frequently as White women. However, there is little acknowledgment of the role that race and culture plays in obtaining care, and how this view could be distorted given so few women feel comfortable speaking on the topic of incontinence and prolapse. This thesis investigates the possible reasons associated with either no presentation or late presentation to care for incontinence and prolapse, and questions whether the captured prevalence in the literature is the true prevalence in our population. I review the research that exists, both quantitative and qualitative, regarding care patterns, patient attitudes and cultural factors, provider knowledge and awareness, and structural factors that facilitate and hinder access to urogynecologic care. I then use an urban bioethical lens to further identify structural bias and racism within healthcare, and inform strategies that may be used to better patient knowledge and education, to allow for more comprehensive and equitable care for women within the field of urogynecology. / Urban Bioethics

Patients with opioid use disorder (OUD) are at a high risk of a patient directed discharge (PDD) from the hospital and subsequent readmission, which is a significant detriment to their health. Qualitative studies have shown that, amidst myriad other reasons, patients with OUD leave the hospital due to undertreatment of their withdrawal and pain. Current guidance for the inpatient medical management of both withdrawal and, more broadly, OUD is initiation of opioid agonist therapy in the form of methadone or buprenorphine. While both have been shown to be highly effective for maintaining remission from OUD, there exist a myriad of barriers to enacting and maintaining this therapy. One approach to address this gap is expanding the array of opioid medications available to patients in withdrawal to include long and short acting opioids. There is limited data on the patient reported outcomes and perspectives of such an approach. This thesis draws from qualitative interviews of patients with OUD about their experiences being treated with this expansive protocol in order to characterize the attributes of successful withdrawal management for this population. Being treated by an addiction medicine team has already been shown to successfully reduce premature discharge. I argue that this approach, considered unorthodox by some, centers a patient's agency in making the decisions that are best for their situation and reduces harm to patients. The current standards of care do a disservice to patients with opioid use disorder, and this is a more progressive and ethical approach to inpatient addiction medicine that should be applied to other hospitals with high volumes of patients with OUD. / Urban Bioethics

The Multi-Visit Patient (MVP) Clinic at Temple University Hospital was established as a community health worker-driven effort to reduce patient readmissions. The clinic employs a multidisciplinary approach, with both social and medical needs addressed at each visit. Patients “graduate” from the program when they are connected with adequate healthcare follow-up outside the clinic. This study aimed to explore the impact of social determinants of health on patient success in the program, with the goal of identifying the types of social support that may be most important for the clinic to provide. A retrospective review was conducted using the social determinants of health screen embedded in Temple University Hospital’s medical record platform. Social determinants of health data was compared between “graduated” patients (n=104) and those lost to follow-up (n=35). Successfully-engaged patients also participated in a survey (n=87). Results revealed no significant differences between the two patient samples in terms of legal sex, marital status, race, ethnicity, housing insecurity, food insecurity, or transportation insecurity. There were no statistically significant differences in readmission rates or emergency department use within 30 days of patients’ last MVP Clinic visit. Among surveyed patients, 64.2% had recently visited a primary care provider and 79.3% reported having social support to help manage their medical conditions. Our results suggest that the examined social barriers are unlikely to be the cause of difficulty engaging with the MVP Clinic, implying that community health worker interventions should continue to be individualized to each patient’s needs. Future studies should explore the impact of other non-quantifiable factors such as patient motivation and positive experiences with the healthcare system on success within the program. / Urban Bioethics

Palliative care is a specialty focused on improving the quality of life for patients with serious illnesses through symptom management and emotional/spiritual support. Despite its documented benefits, it remains largely underutilized among head and neck cancer patients, especially those in urban environments. This thesis reviews obstacles to accessing care in these environments and proposes practical solutions to enhance palliative care accessibility and effectiveness. Disparities in the access and utilization of palliative care are largely influenced by socio-economic status, cultural discrepancies, and healthcare infrastructure, with limited patient awareness further impacting its use. Addressing these challenges requires a comprehensive strategy that includes policy reform, educational outreach, and localized community interventions. Such approaches should be culturally sensitive and tailored to local needs to bridge the gap between medical services and community expectations. By working with patients to recognize palliative care as an integral part of comprehensive cancer care, rather than merely an end-of-life option, we can improve the quality of life for patients with head and neck cancer. / Urban Bioethics

Discussions of autonomy at the end of life in health care contexts is no new phenomenon. However, what seems to have changed in issues of autonomy is cases where patients want to refuse a treatment to cases where patients are demanding more treatment when medical professionals may not agree or be able to provide them with the medical treatment. Some key competing interests impacting patient autonomy include beneficence-doing what is in the best interests of the health or well-being of the patient- and resource limitations. Here, I will explore distributive justice theories that impact the end of life and how they constrain autonomy.

The Temple University Hospital System Ophthalmology Department implemented a telemedicine screening program for diabetic retinopathy to improve patient care and community engagement. The program screened over 1900 patients in the Philadelphia area from March 2016 to March 2020 and identified a significant number of patients who required further in-person examination and treatment. The implementation of a telemedicine screening program for diabetic retinopathy raises important ethical issues and merits discussion of the impact of social determinants of health on healthcare outcomes. In these community initiatives, the principles of agency, beneficence, non-maleficence, social justice, and solidarity in bioethics should be considered as they pertain to the specific needs of the community in which they are implemented. Overall, the COVID-19 pandemic has highlighted the importance of considering the ethical implications of healthcare practices, including diabetic retinopathy screenings. The risks and barriers to access must be taken into account, especially for vulnerable populations in urban areas. As such, promoting primary care engagement, providing accurate and culturally appropriate education and outreach, and addressing social determinants of health can help ensure that all patients have access to comprehensive and equitable care. By considering these factors, diabetic retinopathy screenings can be conducted in an ethical and effective manner. / Urban Bioethics

Objectivity is a valued principle in western allopathic medicine, and for good reason: it has been very effective in saving lives and improving quality of life since the nineteenth century. In recent years, however, there have been many visible accounts in social and mass media describing the consequences of disbelief by physicians, particularly from women and people from marginalized communities. This paper uses an urban bioethics perspective to examine how overreliance on the principle of objectivity can lead to violations of bioethical principles that it should be in balance with.First, media and personal accounts of physician disbelief and misdiagnosis of patients are discussed. This is followed by a brief discussion of the historical roots of objectivity in medicine, an examination of the particular difficulty western medicine seems to have with medically-unexplained symptoms, and a closer look at specific diseases that encounter stigma in the clinical setting. From there, specific bioethical principles are analyzed. Nomaleficence is violated when clinicians traumatize their patients through disbelief of symptoms that cannot be confirmed through confirmatory testing and when they prematurely assume a psychogenic cause of symptoms simply because the cause cannot be found with a physical examination, laboratory test, or imaging study. Solidarity, autonomy, and agency are violated through the denial of the patient’s expertise in their own experience and the disempowerment of the patient in the doctor-patient relationship. Distributive and social justice are violated when the efficiency demanded of a medical system built upon reliance on objective findings disadvantages patients with difficult-to-diagnose conditions along with women and marginalized groups. Potential solutions to the unethical overreliance on objectivity include changes to medical education and culture to be more allowing of fallibility and humility, as well as better integration of mental and behavioral health into the primary care setting, so patients’ medical and psychosocial needs may be treated more holistically. Structural changes to the healthcare system allowing better physician reimbursement for clinical counseling will also mitigate dependency on objective findings for diagnosis and treatment. / Urban Bioethics