Published by John Menadue, Tuesday 14 August

First, the good news. A new code of conduct for medical practitioners, drafted by the Medical Board of Australia, includes a section on working with Aboriginal and Torres Strait Islander people. It’s a signal from the board that the medical profession has important ethical obligations toward Indigenous Australians. The draft code says:

Australia has always been a culturally and linguistically diverse nation. Aboriginal and Torres Strait Islander Peoples have inhabited and cared for the land as the first peoples of Australia for millennia, and their histories and cultures have uniquely shaped our nation. Understanding and acknowledging historic factors such as colonisation and its impact on Aboriginal and Torres Strait Islander Peoples’ health, helps inform care. In particular, Aboriginal and Torres Strait Islander Peoples bear the burden of gross social, cultural and health inequity. In supporting the health of Aboriginal and Torres Strait Islander Peoples, good medical practice involves:

  • Providing care that is holistic, free of bias and racism, challenges belief based upon assumption and is culturally safe and respectful for Aboriginal and Torres Strait Islander Peoples.
  • Advocating for and acting to facilitate access to quality and culturally safe health services for Aboriginal and Torres Strait Islander Peoples.
  • Recognising the importance of family, community, partnership and collaboration in the healthcare decision-making of Aboriginal and Torres Strait Islander Peoples, for both prevention strategies and care delivery.

Now for the bad news. As welcome as this high-sounding rhetoric is, it misses the point: it squibs the fundamental issue about healthcare for Indigenous Australians. In 2016, Aboriginal health services expert Professor Judith Dwyer, with colleagues, conducted an extensive review of the literature on this issue and concluded:

Australian research on differentials in care has established that systemic racism is real, with damaging effects on access and quality. 

There is a huge gap between the life expectancy of Indigenous Australians and non-Indigenous Australians: non-Indigenous males can expect to live 10.6 years longer, and females 9.5 years longer. Aboriginal and Torres Strait Islander people also have a different – worse – experience of the Australian health system than do non-Indigenous Australians.

The most egregious aspects of overt racism are condemned by mainstream Australia. But the evidence about the way Indigenous Australians experience healthcare cannot be dismissed as a random artefact – unconscious racism may be at play. This may be as simple as well-intentioned people thinking that treating Indigenous Australians equally is good practice, when contemporary ethics acknowledge that unequal need warrants unequal care. That is, equal treatment is not enough to overcome Indigenous disadvantage; additional care is required.

It is also important that health professionals ‘see’ the ways in which the practices and policies of healthcare organisations affect Indigenous patients’ access to and quality of care.

A key way to address racism in healthcare, whether unconscious, systemic or institutional, is to call it out and ask health professionals to take additional actions to overcome the bias. For this reason, the Code of Conduct needs to direct medical practitioners’ attention to unconscious bias, and to the steps they need to take to redress it. A new subsection should be added to the Code, instructing doctors that good medical practice also involves:

Recognising that non-Indigenous Australians may exercise unconscious bias in their treatment of Indigenous Australians, who also experience other forms of discrimination in healthcare; and taking steps to overcome bias and address the impacts of discrimination in your treatment decisions.

The time has come to name the systemic bias and unconscious racism. All medical professionals should be directed to reflect on their practice, and whether they are making assumptions about the care of Indigenous Australians that have the unintended consequence of worsening their experience of care and the outcomes of that care.