Social class and medical decisionmaking: a neglected topic in bioethics.

As part of an effort to look at “what differences make a difference” for bioethicists interested in clinical decisionmaking, Erik Parens, the editor of this special section, asked us to look at social class. When we began our research for this paper, we were surprised to find that although bioethicists have written much on social class and such macrolevel issues as access to healthcare and the distribution of scarce resources, and have paid some attention to the effects of class on patient-provider relationships, bioethicists have written little specifically that looks at the implications of social class for medical decisions in individual cases. The neglect of this topic is unfortunate because there are a number of ways in which social class can “make a difference” for medical decisions that are of relevance for bioethicists. First, there are tangible differences in the living conditions of people of different classes leading to differences in health status and in the health services and other resources available to prevent or treat health problems. Second, even when resources are theoretically available, people of different classes may receive differential treatment from providers for the same health conditions due to discrimination on the basis of class. Most bioethicists are aware of these two spheres and see such differences as regrettable. They believe that there should be changes in social conditions and in the delivery of health services to reduce or eliminate such differences, yet there has been little in-depth discussion of the implications of such differences for medical decisions. In addition, there is a third sphere that has received virtually no attention. Because of the differences in their lived experiences, people of different social classes have differences in values relevant to medical decisionmaking. Recently, bioethicists have become much more aware of issues of diversity, in general, and have begun discussing the implications of differences associated with gender, race, religion, and ethnicity. Some bioethicists have called for attention to issues of social class, along with those of race and gender. However, very little work has been done to spell out the relationships between the knowledge and power people experience in different class positions and the ethical values they apply when they enter the realm of biomedicine. The purpose of this paper is to draw attention to the need for bioethicists to pay more attention to issues of social class when examining medical decisions