Blackwell Publishing IncMalden, USAPMEPain Medicine1526-2375American Academy of Pain Medicine?

200795613623
RESEARCH ARTICLESDisparity vs InequityMeghani and Gallagher

PA I N M E D I C I N E
Volume 9 • Number 5 • 2008

ETHICS SECTION

Original Research Article

Disparity vs Inequity: Toward Reconceptualization of Pain
Treatment Disparities

Downloaded from https://academic.oup.com/painmedicine/article/9/5/613/1852051 by guest on 29 April 2024

Salimah H. Meghani, PhD, MBE, CRNP,* and Rollin M. Gallagher, MD, MPH†‡§
*Center for Health Disparities Research, University of Pennsylvania, School of Nursing; †Center for Health Equity Research
and Promotion, Philadelphia Veteran Affairs Medical Center; ‡Center for Pain Medicine, Research and Policy, University
of Pennsylvania; and §Pain Medicine Service, Philadelphia Veteran Affairs Medical Center, Pennsylvania, USA

ABSTRACT

ABSTRACT Context. “Disparity” and “inequity” are two interdependent, yet distinct concepts that inform our
discourse on ethics and morals in pain medicine practice and in health policy. Disparity implies a
difference of some kind, whereas inequity implies unfairness and injustice. An overwhelming body of
literature documents racial/ethnic disparities in health. The debate on health disparities is generally
formulated using the principle of “horizontal equity,” which requires that individuals having the
same needs be treated equally. While some types of health treatments are amenable to the principle
of horizontal equity, others may not be appropriately studied in this way. The existing research
surrounding racial/ethnic disparities in pain treatment presents a conceptual predicament when
placed within the framework of horizontal equity.
Objective. Using pain treatment as a prototype, we advance the conceptual debate about racial/
ethnic disparities in health. More specifically, we ask three questions: (1) When may disparities be
considered inequities? (2) When may disparities not be considered inequities? (3) What are the
uncertainties in the disparity–inequity discourse?
Discussion. Significant policy implications may result from the manner in which health disparities
are conceptualized. Increasingly, researchers and policy makers use the term disparity interchange-
ably with inequity. This usage confuses the meaning and application of these distinct concepts. In
a given health care setting, different types of disparities may operate simultaneously, each requiring
serious scrutiny to avoid categorical interpretation leading to misguided practice and policy. While
the science of pain treatment disparities is still emerging, the authors present one perspective toward
the conceptualization of racial/ethnic disparities in pain treatment.

Key Words. Disparities; Inequities; Pain; Pain Treatment; Race; Ethnicity; Minorities

Introduction

Reprint requests to: Salimah H. Meghani, PhD, MBE,

CRNP, Center for Health Disparities Research, University
“D isparity” and “inequity” are two interde-
pendent, yet distinct concepts. In the lit-
eral sense, disparity merely implies a “difference”
of Pennsylvania, School of Nursing, Claire M. Fagin Hall
418 Curie Blvd., Philadelphia, PA 19104-6096, USA. Tel:
or a “lack of parity” of some kind [1]. Inequity,
215-573-7128; Fax: 215-573-7492; E-mail: meghanis@ on the other hand, implies “a state of being
nursing.upenn.edu. unfair” [1]. In the context of health care, these

© American Academy of Pain Medicine 1526-2375/08/$15.00/613 613–623 doi:10.1111/j.1526-4637.2007.00344.x

614
two concepts may have distinct implications for
practice and policy.
An overwhelming body of literature points to
differential health care access, disease and symp-
tom management, and health care outcomes
between minorities and nonminorities [2]. In
2002, the Institute of Medicine (IOM) published
a 738-page report titled “Unequal Treatment:
Confronting Racial and Ethnic Disparities in
Health Care.” This report synthesized data from
over 100 studies, focus groups, and testimonies
from experts and concluded that racial/ethnic dis-
parities remain pervasive in the American health
care system [2].
In view of the lingering de facto discrimination
that prevails in many sectors of American life, it
can hardly surprise anyone that inequities do exist
within the health care system. It is concerning,
however, that the science of health care disparities
suffers from a conceptual lag due to the way in
which health care disparities are studied and inter-
preted. The existing literature frequently associ-
ates the term disparity with discrimination. This
precludes providers and the public from seeing
beyond the expression into the sources of dispar-
ities and hampers appropriate measurement and
application of this very intricate concept.
Another problem with the science of health care
disparities is that it has traditionally been based on
the quantitative measures of “more and less,” which
appear to have been contemplated using the lens
of “horizontal equity.” Horizontal equity requires
that individuals having the same needs be treated
equally. While some types of treatments and out-
comes are easily amenable to the principles of hor-
izontal equity, others may not be appropriately
studied in this way. The existing research sur-
rounding racial/ethnic disparities in pain treat-
ment presents a conceptual predicament when
placed within the framework of horizontal equity.
Pain treatment therefore can serve as a prototype
for examining the intricate nature of racial/ethnic
disparities in health care and may enable us to
conceptualize pain treatment disparities with
regard to its various dimensions.
The purpose of this article is to use pain treat-
ment as an example to elucidate the complex
nature of the concept of disparity and distinguish
it from other related concepts such as inequity.
More specifically, the authors ask three fundamen-
tal questions: (1) When may disparities be consid-
ered inequities? (2) When may disparities not be
considered inequities? (3) What are the uncertain-
ties in the disparity–inequity discourse? Implicit in
Meghani and Gallagher
this discussion are normative questions: Are dis-
parities intrinsically undesirable? Do they always
imply a moral error? Alternatively, can there be
just and fair disparities?
Racial and Ethnic Disparities in Pain Treatment:
What Is the Evidence?
A growing body of literature points to differential
patterns of analgesic treatment among minority
and nonminority patients. In 1993, Todd et al. [3]
Downloaded from https://academic.oup.com/painmedicine/article/9/5/613/1852051 by guest on 29 April 2024
reported that patients’ race and ethnicity were
independently related to providers’ analgesic pre-
scribing practices in the emergency department
and that minority patients with long bone frac-
tures were less likely to receive analgesia, despite
being insured on a similar level as nonminority
patients. Subsequently, many researchers evalu-
ated the problem of undertreatment of pain
among minorities in a variety of clinical settings
and contexts, including emergency rooms [3–9];
acute postoperative care [10–13]; HIV/AIDS
treatments [14]; cancer treatment [15–18], nursing
homes [19]; and chronic pain setting [20]. Many
of these studies suggest that minorities are at a
greater risk of receiving less analgesia when
compared with nonminority individuals.
In recent years, a number of important articles
have synthesized research on disparities in pain
treatment among racial/ethnic minorities [21–23].
While there is little doubt that minority–nonmi-
nority differences in analgesic treatment exist, the
pathways leading to these disparities remain elu-
sive. Most of the available studies on pain treat-
ment disparities have been conducted within a
linear-quantitative paradigm and allude only to the
technical aspects of disparity, i.e., the types and
amounts of analgesia received by one group vs
another group of patients; these studies offer little
insight into why such differences may exist. For
instance, it is not clear the degree to which pro-
viders or patients contribute to these disparities.
Do these differences represent a systematic bias in
the providers’ analgesic prescribing practice? Or
do they represent a systematic difference in the
need for or expressed desire and negotiation for
analgesics by particular groups of patients? Or,
more likely, do they reflect some interaction of
these factors.
Potential sources of disparities in pain treat-
ment include differences in access, needs, choice
or preferences, attitudes, and expressed demand
for analgesic treatment. The subjective and cul-
tural nature of pain challenges us to conceptualize
Disparity vs Inequity
disparities to incorporate these intricate aspects of
the pain treatment experience. To this end, the
following section provides a discussion of the con-
cepts of disparity and inequity and teases out the
differences in these interdependent concepts using
empirical examples from the pain treatment
disparity literature.
The Term “Disparities,” Its Uses, and Applications
In the United States, health care disparities have
produced high profile policy initiatives [24].
Despite the high importance attached to the
notion of disparity, considerable confusion exists
over what the term actually implies and how oper-
ationally to define the term in a meaningful way
for research. As mentioned above, increasingly,
researchers and policy makers have used the term
disparity interchangeably with inequity [25], con-
fusing the meaning and application of these inter-
dependent, yet distinct concepts. This confusion
is epitomized by the use of varying definitions
of health disparities by agencies and institutions
when presenting policy arguments or discussing
policy initiatives related to health disparities.
For example, the Healthy People 2010 defines
health disparities as “differences that occur by
gender, race or ethnicity, education or income,
disability, geographic location, or sexual orienta-
tion” [26]. The National Institutes of Health
(NIH) defines health disparities as “differences in
the incidence, prevalence, mortality, and burden
of diseases and other adverse health conditions
that exist among specific population groups in the
United States” [27]. Due to its charge to under-
stand racial/ethnic disparities in health, the IOM
defines health disparities as “racial or ethnic dif-
ferences in the quality of health care that are not
due to access-related factors or clinical needs,
preferences and appropriateness of intervention”
(pp. 3–4) [2].
It may be evident that the above three defini-
tions differ conceptually. While Healthy People
2010 defines health disparities in terms of the
sociodemographic characteristics of specific pop-
ulations, the NIH defines disparities with regard
to differences in health outcomes that occur as a
result of having such characteristics. Both defini-
tions use the term disparities to connote “differ-
ences” without assigning any value to the nature
of these differences. The IOM definition, how-
ever, provides a judgment about when differences
may be considered disparities, i.e., differences in
care despite having equal access and or similar
615
preferences. In this context, the IOM definition
more closely reflects the essence of the term ineq-
uity (discussed later) rather than disparity. Thus,
it may be evident that the current usage of the
term disparity in the United States ranges from
connoting a mere difference (value-free) to a
judgment of the nature of such differences
(value-laden).
Linguists such as Chomsky believe that
thoughts and mental processes are distorted when
crucial terms are divorced from their ordinary
Downloaded from https://academic.oup.com/painmedicine/article/9/5/613/1852051 by guest on 29 April 2024
sense usage and assigned a technical meaning [28].
For instance, when a value-free term (such as dis-
parity) is repeatedly associated with a value-laden
term (such as inequity), the value-free term even-
tually becomes value-laden, obscuring its actual
meaning and application.
Disparity vs Inequity
Etymologically, the term “disparity” originated in
the 15th century from the Latin “disparatus,”
which means “to separate” [29]. The Oxford
Advanced Learner’s Dictionary defines disparate as
“(of two or more things) so different from each other
that that they cannot be compared” [1]. It may be
evident that disparity is not inherently a value-
laden term. Consequently, it can be said that dis-
parity is not undesirable in itself unless it results
in some consequence that can be understood as
unfair or unjust.
Unlike disparities, inequities are always unde-
sirable and should be subject to serious moral crit-
icism. Inequity, by definition, is the “state of being
unfair” [1]. Many equity theories have been pro-
mulgated over the years in an attempt to identify
the best principles of distributive justice for better-
and worse-off groups [30–39]. Equity implies “the
application of the principles of natural justice in a
particular circumstance where the existing . . .
[structures] would not allow fair or reasonable
result” [1] and entails a constant battle between
ideology and existing resources [40]. Equity theo-
rists deal with the moral justification and the
individual and shared social consequences of dis-
tributive injustice to a given society [41]. While
equality is at the core of equity theories, equality
in this sense does not necessarily mean a literal
parity, but rather equality per unit of some good in
question. Units in this sense might be understood
as needs, preferences, advantages, disadvantages,
inputs, outputs, and the like. Thus, equality and
equity are overlapping concepts—the only con-
ceivable ideal where equality perfectly equals
616 Meghani and Gallagher

Disparities

Inequality Inequity
(Value-free) (Value-laden)

Behaviors freely Systematically

Inevitable causes Unfair
chosen by rational important
(natural causes) and avoidable
people* differences

Downloaded from https://academic.oup.com/painmedicine/article/9/5/613/1852051 by guest on 29 April 2024

Who/what we ought to be?
Who we are?
(compared with some reference group)

Figure 1 Disparities vs inequities. Adapted from Whitehead, 1985 [30]. * Utilitarians argue that if a behavior may have bad
consequences for individuals or society, it is unjust for that behavior, even if it is freely chosen by a rational being.

equity is a utopian society, where the needs, pref-
erences, inputs, and outputs of all members are
exactly the same. Thus, it may be said that not all
disparities are inequities—in effect, equal is not
always equitable and equitable need not be equal.
If it may be established that the needs of different
individuals or groups are significantly different
from the other, then providing an equal treatment
may actually be inequitable.
When Do Disparities Equal Inequities?
Disparities range from mere differences to differ-
ences occurring as a result of moral error in the
way care or services are provided (Figure 1). These
latter differences are termed inequities (Table 1).
According to Whitehead, “The term inequity has
a moral and ethical dimension. It refers to differ-
ences which are unnecessary and avoidable but, in
addition, are also considered unfair and unjust”
[32]. Based on the above definition, the use of the
term inequity should inevitably imply judgments
about important systematic differences that are
judged to be unfair and result from unnatural and
mutable causes [32].
Many theorists have promulgated what they
consider as the best principle for the attainment of
distributional equity. The unsettling debate, how-

Table 1 Definitions and examples of inequities and its dimensions

Construct Definition Examples
Macrolevel inequities Systematic conditions and factors operating • Unavailability of opioids in pharmacies serving minority and
on a system-level limiting equal access and poor neighborhoods [47,48].
opportunities.
Microlevel inequities Systematic conditions and factors operating • Inadequate assessment of pain in a patient with limited
in patient–provider encounter limiting equal English proficiency.
access and opportunities. • Physician failure to treat acute pain after abdominal
surgery with adequate doses of opioids because patient is
on methadone maintenance for heroin addiction.
• Failure to treat pain in a black person with tattoos who
comes to the emergency room with severe back pain or
headache.
Horizontal inequities Failure to provide same treatment to • Lack of access to pain medicine specialists due to
individuals with similar needs. socioeconomic constraints such as poverty or lack of
insurance.
• Failure to provide workers’ compensation support and
access to medical treatment for persons with low back pain
who are black [50–53] or emotionally distressed [54].
Vertical inequities Failure to provide dissimilar but equitable • Provision of similar analgesic treatment despite differential
treatment to those with lesser or greater need or preference, e.g., prescription of codeine or
needs. morphine to individuals or groups with known defects in the
metabolism of these analgesics [63,64].
Disparity vs Inequity
ever, has led some to comment that “. . . equity,
like beauty, is in the mind of the beholder” [42].
Some theorists have argued that decisions on
health care distribution ought to be based on
something as instrumental as “need” [43] while
others have argued that equality of access and equal-
ity of opportunity should be the criteria [44]. Yet
others have argued that equality of access should
be interpreted as actual utilization and not merely
the potential for access itself [44]. Finally, some
have asserted that the ultimate criterion for equi-
table decisions ought to be health itself, which is
instrumental for equality of flourishing [36]. The
moral philosopher Rawls, in his theory Justice as
Fairness, asserts, “All . . . primary goods . . . are to
be distributed equally unless an unequal distribu-
tion of any or all of these goods is to the advantage
of the least favored” [italics added] [45].
Macrolevel and Microlevel Inequities
Inequities can occur both at macro and micro lev-
els (see Table 1). Macrolevel inequities occur when
preconceived notions about groups defined by
individual characteristics such as race, ethnicity,
gender, or social status systematically operate to
limit equal access and opportunities when com-
pared with reference groups.
Evidence is accumulating that the members of
racial/ethnic minorities have different opportuni-
ties to receive care such that patients with similar
social characteristics, such as similar health insur-
ances, may be treated differently [2]. Krieger
asserted that while the U.S. social system may have
been somewhat successful in minimizing “de jure”
(by law) discrimination, “de facto” (in fact) dis-
crimination is still highly prevalent in our social
system [46]. “De facto” discrimination with regard
to health care is problematic, not only because of
its harmful effects on the health of an individual
or society but because it is bad in itself [46].
A lack of geographic access to opioids in minor-
ity neighborhoods [47,48] is another example of
macrolevel inequity in pain treatment. The com-
partmentalization of social sectors and residential
segregation of minorities in the United States has
created avenues of focal disadvantages [47–49].
The discharge of two patients from the same hos-
pital with similar prescriptions for analgesics does
not guarantee equal access to the recommended
treatment. This was epitomized in the study “We
don’t carry that,” published in the New England
Journal of Medicine [47]. A random sample of 30%
of pharmacies in the five boroughs of New York
617
City was surveyed to determine the availability of
commonly prescribed opioids in predominantly
nonwhite neighborhoods. Only 25% of pharma-
cies in predominantly nonwhite areas (<40%
white) had opioids that were sufficient to treat
severe pain, in comparison with 72% of pharma-
cies in predominantly white neighborhoods
(≥80% white).
More recently, research led by Green et al. [48]
reported a significant gap in the availability of
prescription opioid analgesics in minority and
Downloaded from https://academic.oup.com/painmedicine/article/9/5/613/1852051 by guest on 29 April 2024
poor neighborhoods of Michigan. The study was
conducted with 190 pharmacies in zip codes with
predominantly white populations (≥70% white
residents) and in zip codes with predominantly
minority populations (≥70% minority residents).
After stratifying for income and controlling for zip
code and median age, pharmacies in white areas
(odds ratio, 13.36 high income vs 54.42 low
income) and noncorporate pharmacies (odds ratio,
24.92 high income vs 3.61 low income) were more
likely to have sufficient opioid analgesic supplies
(P < 0.005). The authors concluded that regardless
of income, Michigan pharmacies in predominantly
minority zip codes were significantly less likely to
carry sufficient prescription opioids than pharma-
cies in predominantly white zip codes.
Microlevel inequities in pain treatment occur
when individuals or groups lack access to similar
advantages such as appropriate assessment, ef-
fective communication, concordance between
patients and providers resulting in differential
pain treatment outcomes. For instance, emerging
research by Tait, Chibnall, and colleagues suggests
that African American Workers’ Compensation
claimants with low back injuries receive lower
compensation, medical expenditures, disability
ratings, and settlement awards relative to Cauca-
sians [50–53]. Similarly, Gallagher et al. have
noted that in persons out of work from low back
pain, controlling for other factors including sever-
ity of injury and impairment, those with emotional
distress are less likely to be awarded workers
compensation [54]. These differential outcomes
appear to be mediated by a model of social judg-
ment that operates at the level of patient–provider,
case management, and jurisdiction [50,52]. Other
clinical examples of microlevel inequities include
inefficient pain treatment among minorities
related to provider attitude toward pain [55,56],
reluctance to prescribe pain medications [56], and
limited concordance between patient and provider
estimates of pain [15,17]. Unlike macrolevel ineq-
uities resulting from lack of access, microlevel
618
inequities are difficult to characterize and require
further understanding of pathways leading to such
disparate outcomes.
For instance, in the setting of pain treatment,
“effective pain treatment” is a desirable outcome
for all patients with clinical pain. This outcome is
judged by one or more subjective or objective
measures, rather than, simply, by the milligram
dose of a given medication. Thus, the provider
would not only necessarily adjust the milligram
dose of analgesic, but also assure access to other
treatments and supports needed to assure similar
outcomes. In a simplistic example, if a middle-
aged worker presents to the pain clinic with her-
niated lumbar disk and radiculopathy, two desired
outcomes are pain control and return to work.
Equity is assured only if equal access to the indicated
treatment necessary for both pain control and
return to work is provided—in this case, pain con-
trol with oral analgesics or epidural medications
accompanied by appropriate rehabilitation (not
just “physical therapy” but also behavioral therapy
as necessary). Health managed organizations or
entitlement programs often allow basic medical
treatment, but limit access to other treatments that
improve the odds of functional recovery [57,58].
Hence, solutions to macrolevel and microlevel
inequities in access to pain treatment require pol-
icies in medical education that improve the stan-
dards of training for pain care [59] and also
policies that improve the population-based distri-
bution of standard pain treatments [60].
When Are Disparities Not Inequities?
Based on the Aristotelian notion of justice, equity
in health care requires that “patients who are alike
in relevant respects be treated in like fashion and
that patients who are unlike in relevant respects be
treated in appropriately unlike fashion” [34] (p.
275). The treatment of individuals may be consid-
ered equitable if it relates to some way in which
individuals are reasonably considered similar or
dissimilar, for instance, with regard to “need” or
“health” [34]. It follows that, with regard to rele-
vant characteristics, people with like needs should
receive like treatment (horizontal equity) and
people with lesser or greater needs should,
respectively, receive lesser or greater treatments
(vertical equity). These two types of equities have
considerably distinct policy implications and must
appeal to some ethical principle to justify the
deliberate choice of one over the other. For
instance, the idea of universal health coverage or
Meghani and Gallagher
access to health services appeals to horizontal
equity, whereas provision of targeted health pro-
grams and services based on established needs may
appeal to vertical equity principles [61]. The
Veteran Affairs Health System is one example of
horizontal equity in access, as military veterans,
regardless of their socioeconomic status and their
ability to pay, can receive care in the system. How-
ever, microlevel inequities (see Table 1), such as
failure to adequately treat postsurgical pain in
opioid dependent patients, may persist.
Downloaded from https://academic.oup.com/painmedicine/article/9/5/613/1852051 by guest on 29 April 2024
Vertical equity principles inevitably require
providers and policy makers to interpret and
define needs based on some reasonable or scientific
criteria. Equity decisions may not be based on
“irrelevant” or “immutable” characteristics such as
race or gender [34], but for a difference of “need”
that may arise from having such characteristics.
Race and the Case for Scientific Discrimination?
Race remains a contentious notion within the sci-
entific community. There is considerable debate
on whether race is a biological construct or a
socially determined phenomenon. As the relation-
ship between race, ethnicity, and genetics remains
murky, so is the question, “Is there a room for
scientific discrimination based on biological char-
acteristics of individuals and groups?” This ques-
tion is subject to further debate and discussion. In
the pain literature, some studies point to signifi-
cantly disparate pharmacokinetics and pharmaco-
dynamics of analgesic drugs between and within
different racial/ethnic groups [62–64]. Some
emerging evidence identifies genetic polymor-
phism as an important source of variation in anal-
gesic metabolism and response among individuals
and groups. Genetic polymorphism results in an
alteration in the enzymatic activity of a hepatic
Cytochrome P450 (CYP2D6). The polymorphic
CYP2D6 is a drug-metabolizing enzyme, which is
necessary for the conversion and metabolism of a
number of widely used opioid analgesics [65] and
other medications used in pain medicine practice,
e.g., anticonvulsants (phenytoin), benzodiazepines
(diazepam), muscle relaxants (succinylcholine),
antidepressants (imipramine, nortriptyline, ven-
lafaxine), typical neuroleptics, alcohol, antihyper-
tensive medications (propranolol, timolol), local
anesthetics (procainamide), l-dopa, nicotine, and
warfarin [66].
Two distinct phenotypes, i.e., the poor metab-
olizer (PM) and the extensive metabolizer (EM),
have been documented across general populations.
Disparity vs Inequity
Individuals with CYP2D6 PM phenotype are
unable to metabolize codeine to morphine and
thus reap minimal therapeutic benefit from
codeine [58]. Evidence suggests that about 10% of
Caucasians are characterized as having PM phe-
notype [67]. The clinical implications of CYP2D6
polymorphism are not well documented. How-
ever, at least one recent clinical study of postoper-
ative pain suggests that Caucasians with CYP2D6
PM phenotype had a significantly decreased
response rate to analgesic treatment with trama-
dol, requiring a higher consumption of this anal-
gesic, and more rescue medications than other
Caucasian patients with EM phenotype [68].
The discussion of biological factors as a poten-
tial lurking variable in the genesis of pain treat-
ment disparities is largely absent in present
research. Large-scale studies are needed to deter-
mine if CYP2D6 genotyping has clinical relevance
in the use of several opioids analgesics between
and among groups. Thus, it is not clear if the
results of the pain disparity research will be differ-
ent if the researchers could control for the anal-
gesics known to metabolize through CYP2D6
enzymatic activity. Notwithstanding our limita-
tions in the understanding of pharmacogenomics
of analgesics in different individuals and groups, it
can be said that if relative differences in treatment
result from differences in physiological and bio-
logical processes, rather than problems with access
and availability, they may not be characterized as
inequitable.
For the sake of exemplifying the above argu-
ment, assume that two individuals are exactly sim-
ilar except in their ability to metabolize analgesic
medications. Further, assume that, given the same
injury and nociceptive stimulus, the person A
requires 10 mg of analgesic X for 4 hours of pain
relief and the person B requires 20 mg of analgesic
X for 4 hours of pain relief; then, the equity prin-
ciple may require that the person A be treated with
60 mg of analgesic X per day and the person B be
treated with 120 mg of analgesic X per day to
provide equitable pain relief. Thus, the vertical
equity principle may call for a differential alloca-
tion of goods to those who may be different in
their needs. It is important to underscore, how-
ever, that differential treatment of any sort
requires a strong scientific and moral justification
due to the normative risk for “slippery slope.” For
instance, health providers may illegitimately seek
refuge in the “biological argument” for lack of
equal treatment, resulting in further poor treat-
ment for some groups.
619
The Gray Areas: What Is Fair and Just?
As noted above, equity is a pluralistic concept.
While most agree that equity in the context of
health care implies some mechanism for deter-
mining a just system for treatment or allocation,
no consensus exists on what constitutes a just
and fair treatment. Often, policy development in
the domain of social distribution is not based on
equity judgments for individuals, but rather for
populations and subpopulations. Policy makers
Downloaded from https://academic.oup.com/painmedicine/article/9/5/613/1852051 by guest on 29 April 2024
often resort to the idea that needs are more mor-
ally persuasive in the allocation of treatment and
should be interpreted in a more technical sense
than mere preferences [36]. Consequently, the
notion of justice often competes with other ethi-
cal values such as individual autonomy, choice,
wants, and preferences. The health care system
has been traditionally ineffective in incorporat-
ing these latter values in equity strategy [61]. To
this end, an important question that needs care-
ful discussion remains “can a person’s choice,
wants, and preferences take priority over jus-
tice?” Again, the setting of pain treatment pro-
vides an avenue to consider this important
question.
Some regard pain as “inherently a social
experience” [69]. Indeed, treatment of pain, due
to its very nature, is an interactive social process.
Like any social interaction, the negotiation of
pain treatment between patients and providers
does not occur in isolation from sociocultural
realities. While the precise role of culture in
shaping pain experiences across different ethnic
groups is not well known, it has been widely
argued that culture and ethnicity play an impor-
tant role in the social construction of pain and
in shaping its experience. Despite significant
advancement in understanding the complex
anatomy, physiology, and molecular biology of
pain, the multidimensionality of the human pain
experience renders its precise definition and
measurement elusive. No clinical assay or objec-
tive test to date accurately measures the experi-
ence of pain. Treatment of pain necessitates a
covert interpretation of pain and suffering and
overt negotiation between patients and provid-
ers, which then results in a given treatment plan
[70]. The cycle of pain treatment can potentially
break down at several levels during patient–pro-
vider interaction, resulting in so-called disparity
[70]. For instance, a cancer patient’s negotiation
of pain treatment with a provider may depend
on the meaning and significance that the patient
620
attributes to cancer pain. If the patient believes
that analgesics will mask the symptoms of cancer
progression, he/she may refrain from actively
pursuing pain treatment with providers [70].
The IOM report therefore asserts that “given
the role of cultural and linguistic factors in both
patients’ perception of pain and in physicians’
ability to accurately assess patients’ pain . . . it is
reasonable to suspect that healthcare disparities
might be greater in pain treatment . . . than in
treatment of objectively verifiable disease” (p.
64) [2].
It has been agreed for a long time now that pain
is “whatever the experiencing person says it is and
exists whenever he says it does” (p. 7) [71]. By
extension, can it also be argued that the “treatment
of pain is whatever the experiencing person says it
should be”? Some patients may prefer less pain
medication because they may choose acupuncture
to alleviate their pain; others may resort to spiri-
tuality and praying to cope with their pain, yet
others may choose to refuse pain medication due
to beliefs in endurance and salvation. Some
individuals, based on how they metabolize pain
medication, and experience side effects (past out-
comes), may prefer and demand more or less
analgesia.
Many philosophers and ethicists agree that the
arguments in favor of “need” are more compelling
morally due to their factual and categorical nature
and the ends they are presumed to serve [34].
Unlike “needs,” “wants and preferences” are based
on subjective things such as meanings, past out-
comes with treatments, and social and cultural val-
ues. While “health” is an example of a good that
is often distributed based on needs, health itself is
not categorical or absolute [34]. It may be implied
then that health care ought to improve health. What
constitutes health for different groups or people,
however, is based on the meanings they ascribe
to it.
Thus, it is not clear if cultural appropriateness,
patient autonomy, and equal liberty are better vir-
tues than equality. This also prompts the ques-
tion, does commitment to beneficence take priority
over autonomy? Or should preference, merely
because it is subjective and difficult to quantify,
qualify as having inferior moral status than
“needs”? According to Whitehead, the so per-
ceived “health damaging behavior” that is freely
chosen and results in poor health would be con-
sidered neither unfair nor unjust [30]. One cau-
tion with “preference” is that it can be shaped by
all the wrong reasons (e.g., the belief that in acute
Meghani and Gallagher
back injury, surgery is the best treatment) and
may not necessarily represent a free and informed
choice. Contrarily, some commentators have
argued that equity takes priority over preference
and that individuals be treated equitably even if a
“majority [of them] may prefer an inequitable
alternative” (p. 13) [72].
One seeming paradox in addressing health care
disparities is that on the one hand, the health sys-
tem is striving to achieve equality of care and out-
comes and on the other hand, the flourishing field
Downloaded from https://academic.oup.com/painmedicine/article/9/5/613/1852051 by guest on 29 April 2024
of culturally congruent and individualized medi-
cine is calling attention to plurality of needs and
preferences across different groups. The problem
here is not that the goals of equitable and cultur-
ally appropriate care are antithetical but in what
way can this diversity and multiculturalism be cap-
tured using appropriate measurements so that
legitimate differences are not inadvertently per-
ceived as inequities resulting in misguided practice
and policy implications.
Conclusions
Disparities in health care exist, but the term
“disparities” is often confused with a related but
meaningfully different concept, “inequities.” The
article used pain treatment disparities to examine
the question, are all disparities in health care
intrinsically bad? Further, it advances the notion
that disparities are an inevitable reality of any
institution (e.g., health care) that intimately deals
with the diversities of human life and intricacies of
human nature. As disparities are not categorical,
their resolution cannot be categorical either. For
instance, elimination of gradient in the sense of
“more or less treatment” is laudable and appropriate
in the context of access and availability but may
be murky in such settings that deal with a range
of human experiences and disparities in needs,
choices, wants, and preferences. The essence of
this argument may be deduced from the following
observation by Coffin: “We must always press the
socialist questions. But be careful and dubious
about the socialist answers . . . socialist questions
are questions about justice . . . you can say . . . let
justice roll down like mighty waters, but figuring
out the irrigation system is complicated . . . what’s
the best irrigation system, maybe combination of
a lot of things” [73].
While evidence related to system-level barriers
in pain treatment disparities are well documented,
understanding of patient–provider factors, as well
as basic science, e.g., possible variations in drug
Disparity vs Inequity
metabolism, remain rudimentary. The framework
we propose in this article will help investigators
consider different factors affecting pain treatment
disparities and help identify areas that need further
study in understanding and addressing these
disparities.
Acknowledgments
We are extremely thankful to Anne Keane, EdD, CRNP,
FAAN, for her guidance, support, and encouragement with
various aspects of this article.
References
1 Oxford Advanced Learner’s Dictionary. Oxford:
Oxford University Press; 1998.
2 Smedley BD, Stith AY, Nelson AR, eds. Unequal
Treatment. Confronting Racial and Ethnic Dispar-
ities in Health Care. Washington, DC: National
Academic Press; 2002.
3 Todd KH, Samaroo N, Hoffman JR. Ethnicity as a
risk factor for inadequate emergency department
analgesia. JAMA 1993;269(12):1537–9.
4 Heins JK, Heins A, Grammas M, Costello M,
Huang K, Mishra S. Disparities in analgesia and
opioid prescribing practices for patients with mus-
culoskeletal pain in the emergency department.
J Emerg Nurs 2006;32(3):219–24.
5 Fuentes EF, Kohn MA, Neighbor ML. Lack of asso-
ciation between patient ethnicity or race and fracture
analgesia. Acad Emerg Med 2002;9(9):910–5.
6 Singer AJ, Thode HC Jr. National analgesia
prescribing patterns in emergency department
patients with burns. J Burn Care Rehabil 2002;
23(6):361–5.
7 Tamayo-Sarver JH, Dawson NV, Hinze SW, et al.
The effect of race/ethnicity and desirable social
characteristics on physicians’ decisions to prescribe
opioid analgesics. Acad Emerg Med 2003;10(11):
1239–48.
8 Todd KH, Lee T, Hoffman JR. The effect of
ethnicity on physician estimates of pain severity in
patients with isolated extremity trauma. JAMA
1994;271(12):925–8.
9 Yen K, Kim M, Stremski ES, Gorelick MH. Effect
of ethnicity and race on the use of pain medications
in children with long bone fractures in the emer-
gency department. Ann Emerg Med 2003;42(1):41–
7.
10 McDonald DD. Gender and ethnic stereotyping
and narcotic analgesic administration. Res Nurs
Health 1994;17(1):45–9.
11 Adamson J, Ben-Shlomo Y, Chaturvedi N, Dono-
van J. Ethnicity, socio-economic position and gen-
der – do they affect reported health-care seeking
behaviour? Soc Sci Med 2003;57(5):895–904.
621
12 Ng B, Dimsdale JE, Rollnik JD, Shapiro H. The
effect of ethnicity on prescriptions for patient-
controlled analgesia for post-operative pain. Pain
1996;66(1):9–12.
13 Ng B, Dimsdale JE, Shragg GP, Deutsch R. Ethnic
differences in analgesic consumption for postoper-
ative pain. Psychosom Med 1996;58(2):125–9.
14 Sambamoorthi U, Walkup J, McSpiritt E, Warner
L, Castle N, Crystal S. Racial differences in end-of-
life care for patients with AIDS. AIDS Public Policy
J 2000;15(3–4):136–48.
15 Anderson KO, Mendoza TR, Valero V, et al.
Downloaded from https://academic.oup.com/painmedicine/article/9/5/613/1852051 by guest on 29 April 2024
Minority cancer patients and their providers: Pain
management attitudes and practice. Cancer 2000;
88(8):1929–38.
16 Anderson KO, Richman SP, Hurley J, et al. Cancer
pain management among underserved minority out-
patients: Perceived needs and barriers to optimal
control. Cancer 2002;94(8):2295–304.
17 Cleeland CS, Gonin R, Baez L, Loehrer P, Pandya
KJ. Pain and treatment of pain in minority patients
with cancer. The Eastern Cooperative Oncology
Group Minority Outpatient Pain Study. Ann Intern
Med 1997;127(9):813–6.
18 Cleeland CS, Gonin R, Hatfield AK, et al. Pain and
its treatment in outpatients with metastatic cancer.
N Engl J Med 1994;330(9):592–6.
19 Bernabei R, Gambassi G, Lapane K, et al. Manage-
ment of pain in elderly patients with cancer. SAGE
Study Group. Systematic Assessment of Geriatric
Drug Use via Epidemiology. JAMA 1998;279(23):
1877–82.
20 Chen I, Kurz J, Pasanen M, et al. Racial differences
in opioid use for chronic nonmalignant pain. J Gen
Intern Med 2005;20(7):593–8.
21 Bonham VL. Race, ethnicity, and pain treatment:
Striving to understand the causes and solutions to
the disparities in pain treatment. J Law Med Ethics
2001;29(1):52–68.
22 Green CR, Anderson KO, Baker TA, et al. The
unequal burden of pain: Confronting racial and eth-
nic disparities in pain. Pain Med 2003;4(3):277–94.
23 Ezenwa MO, Ameringer S, Ward SE, Serlin RC.
Racial and ethnic disparities in pain management in
the United States. J Nurs Scholarsh 2006;38(3):
225–33.
24 United States Department of Health and Human
Services. HHS awards more than $56 million to
eliminate health disparities. January 9, 2006.
Available at: http://ncmhd.nih.gov/SawardsM.html
(accessed November 8, 2006).
25 Almond P. An analysis of the concept of equity and
its application to health visiting. J Adv Nurs
2002;37(6):598–606.
26 U.S. Department of Health & Human Services.
Healthy people 2010: Understanding and improv-
ing health, 2nd edn. 2000. Available at: http://
www.healthypeople.gov/Document/html/uih/
uih_2.htm#goals (accessed July 5, 2007).
622
27 National Institute of Health. Addressing health
disparities: The NIH program of action. 2004.
Available at: http://healthdisparities.nih.gov/whatare.
html (accessed July 5, 2007).
28 Chomsky N. Thought control in the US: The
media and the “Peace Process.” MERIP Middle
East Report 1986;143:25–9.
29 Merriam-Webster Online. Disparate. 2006. Avail-
able at: http://www.m-w.com/ (accessed November
10, 2006).
30 Whitehead M. The concepts and principles of
equity and health. 1985. Available at: http://
www.who.dk/Document/PAE/conceptsrpd414.pdf
(accessed November 10, 2006).
31 Whitehead M, Dahlgren G. What can be done
about inequalities in health? Lancet 1991;
338(8774):1059–63.
32 Whitehead M, Drever F. Narrowing social inequal-
ities in health? Analysis of trends in mortality
among babies of lone mothers (abridged version 2).
BMJ 1999;318(7188):912–4.
33 Whitehead M, Scott-Samuel A, Dahlgren G.
Setting targets to address inequalities in health.
Lancet 1998;351(9111):1279–82.
34 Culyer AJ. Equity – some theory and its policy
implications. J Med Ethics 2001;27(4):275–83.
35 Culyer AJ, van Doorslaer E, Wagstaff A. Utilisation
as a measure of equity by Mooney, Hall, Donaldson
and Gerard. J Health Econ 1992;11(1):93–8.
36 Culyer AJ, Wagstaff A. Equity and equality in
health and health care. J Health Econ 1993;12(4):
431–57.
37 Mooney G. Vertical equity in health care res-
ource allocation. Health Care Anal 2000;8(3):
203–15.
38 Mooney G, Hall J, Donaldson C, Gerard K. Utili-
sation as a measure of equity: Weighing heat?
J Health Econ 1991;10(4):475–80.
39 Mooney G, Jan S. Vertical equity: Weighting out-
comes? or establishing procedures? Health Policy
1997;39(1):79–87.
40 Carter-Pokras O, Baquet C. What is a “health dis-
parity?” Public Health Rep 2002;117(5):426–34.
41 Cook KS, Messick DM. Psychological and sociolog-
ical perspectives on distributive justice: Convergent,
divergent, and parallel lines. In: Cook KS, ed.
Equity Theory. New York: Praeger Publishers;
1983:1–12.
42 McLachlan G, Maynard A. The Public/Private Mix
for Health: The Relevance and Effects of Change.
London: Nuffield Provincial Hospitals Trust; 1982.
43 Culyer AJ. Need and the National Health Service.
York: Studies in Economics; 1976.
44 Mooney GH. Equity in health care: Confronting
the confusion. Eff Health Care 1983;1(4):179–85.
45 Rawls J. A Theory of Justice. Cambridge, MA: The
Belknap Press of Harvard University Press; 1971.
46 Krieger N. Embodying inequality: a review of con-
cepts, measures, and methods for studying health
Meghani and Gallagher
consequences of discrimination. Int J Health Serv
1999;29(2):295–52.
47 Morrison RS, Wallenstein S, Natale DK, Senzel RS,
Huang LL. “We don’t carry that” – failure of phar-
macies in predominantly nonwhite neighborhoods
to stock opioid analgesics. N Engl J Med
2000;34(14):1023–6.
48 Green CR, Ndao-Brumblay SK, West B, Wash-
ington T. Differences in prescription opioid anal-
gesic availability: Comparing minority and white
pharmacies across Michigan. J Pain 2005;6(10):
689–99.
Downloaded from https://academic.oup.com/painmedicine/article/9/5/613/1852051 by guest on 29 April 2024
49 Williams DR, Neighbours HW, Jackson JS. Racial/
ethnic discrimination and health: Findings from
community studies. Am J Public Health
2003;93:200–8.
50 Chibnall JT, Tait RC. Disparities in occupational
low back injuries: Predicting pain-related disability
from satisfaction with case management in African
Americans and Caucasians. Pain Med 2005;6(1):39–
48.
51 Chibnall JT, Tait RC, Andresen EM, Hadler NM.
Race differences in diagnosis and surgery for occu-
pational low back injuries. Spine 2006;31(11):1272–
5.
52 Tait RC, Chibnall JT. Work injury management of
refractory low back pain: Relations with ethnicity,
legal representation and diagnosis. Pain 2001;91(1–
2):47–56.
53 Tait RC, Chibnall JT, Andresen EM, Hadler NM.
Management of occupational back injuries: Differ-
ences among African Americans and Caucasians.
Pain 2004;112(3):389–96.
54 Gallagher RM, Williams RA, Skelly J, et al. Work-
ers’ compensation and return-to-work in low back
pain. Pain 1995;61(2):299–307.
55 Cleeland CS, Cleeland LM, Dar R, Rinehardt LC.
Factors influencing physician management of can-
cer pain. Cancer 1986;58(3):796–800.
56 Von Roenn JH, Cleeland CS, Gonin R, Hatfield
AK, Pandya KJ. Physician attitudes and practice in
cancer pain management. A survey from the Eastern
Cooperative Oncology Group. Ann Intern Med
1993;119(2):121–6.
57 Gallagher RM. Primary care and pain medicine. A
community solution to the public health problem of
chronic pain. Med Clin North Am 1999;83(3):555–
83, v.
58 Gallagher RM. The pain medicine and primary care
community rehabilitation model: Monitored care
for pain disorders in multiple settings. Clin J Pain
1999;15(1):1–3.
59 Fishman SM, Gallagher RM, Carr DB, Sullivan
LW. The case for pain medicine. Pain Med
2004;5(3):281–6.
60 Weiner DK, Kim YS, Bonino P, Wang T. Low
back pain in older adults: Are we utilizing
healthcare resources wisely? Pain Med 2006;7(2):
143–50.
Disparity vs Inequity
61 PAHO/WHO. Principles and basic concepts of
equity and health. 1999. Available at: http://
www.paho.org/english/hdp/hdd/pahowho.pdf
(accessed October 30, 2004).
62 Burroughs VJ, Maxey RW, Levy RA. Racial and
ethnic differences in response to medicines:
Towards individualized pharmaceutical treatment.
J Natl Med Assoc 2002;94(10 Suppl.):1–26.
63 Kim K, Johnson JA, Derendorf H. Differences in
drug pharmacokinetics between East Asians and
Caucasians and the role of genetic polymorphisms.
J Clin Pharmacol 2004;44(10):1083–105.
64 Cepeda MS, Farrar JT, Roa JH, et al. Ethnicity influ-
ences morphine pharmacokinetics and pharmacody-
namics. Clin Pharmacol Ther 2001;70(4):351–61.
65 Dayer P, Desmeules J, Collart L. Pharmacology of
tramadol. Drugs 1997;53(Suppl. 2):18–24.
66 Fishbain DA, Fishbain D, Lewis J, et al. Genetic
testing for enzymes of drug metabolism: Does it have
clinical utility for pain medicine at the present time?
A structured review. Pain Med 2004;5(1):81–93.
67 Eckhardt K, Li S, Ammon S, Schanzle G, Mikus G,
Eichelbaum M. Same incidence of adverse drug
623
events after codeine administration irrespective of
the genetically determined differences in morphine
formation. Pain 1998;76(1–2):27–33.
68 Stamer UM, Lehnen K, Hothker F, et al. Impact
of CYP2D6 genotype on postoperative tramadol
analgesia. Pain 2003;105(1–2):231–8.
69 Moore RJ, Spiegel D. Uses of guided imagery for
pain control by African-American and White
women with metastatic breast cancer. Integr Med
1999;2(2/3):115–26.
70 Meghani SH. Factors affecting the negotiation of
treatment for cancer pain among African Americans
Downloaded from https://academic.oup.com/painmedicine/article/9/5/613/1852051 by guest on 29 April 2024
[Dissertation]. Philadelphia: University of Pennsyl-
vania Diss, 2005. POPM2005.242. University
Microfilm, P38.
71 McCaffery M. Pain: Clinical Manual for Nursing
Practice, 2nd edn. St. Louis: Mosby; 1989.
72 Johnson C. Equity: Its Scope and Its Relation to
Other Objectives. College Park, MD: Center for
Philosophy and Public Policy; 1978.
73 Coffin WS. NOW with Bill Moyers. 2004. Avail-
able at: http://www.zionsherald.org/May2004_
interview.html (accessed February 7, 2005).