Peace and Conflict Studies - Spring 2014

Peace and Conflict Studies Volume 21, Number 1 53 Structural Violence and Cultural Violence in End-of-Life Care Minority patients dying in acute care facilities are rendered invisible and at best, are a marginalized group within the healthcare system who are victims of structural violence. Structural violence is a process by which social or institutional structures (e.g., legal, religious, political, economical) perpetuate unequal power distributions that prevent certain groups from fulfilling basic needs such as survival, wellbeing, identity, and freedom (Galtung, 1990). This type of violence is structural because it is ingrained in the political and economic systems that form our social world; violent because it is preventable and it injures members of the society, usually those that are more distressed or destitute (Farmer et al., 2006). The “underdogs” can be so disadvantaged in this relationship that they can die or be in a “permanent state of misery” (Galtung, 1990, p 293). In the healthcare and legal systems, insurance companies, hospitals, and schools of medicine there are plentiful evidence of structural violence that are sources of healthcare disparities for minorities and interfere with providing adequate care to the dying patient (IOM, 1997; IOMNA, 2002). Examples include economic barriers due to inadequate healthcare insurance, social barriers that prevent equal access to care in comparison to whites, and underrepresentation of minority clinicians in medicine (Krakauer et al., 2002). These barriers have a direct impact on patients’ wellbeing and survival (Moseley & Kershaw, 2012). Several studies have shown that some physicians perceive black patients as less intelligent, less cooperative, less likely to comply with treatment plans, and more likely to engage in destructive behavior such as drug abuse when compared to white patients (Ryn & Burke, 2000; Sabin, Nosek, Greenwald, & Rivara, 2009; Weng & Korte, 2012). Physicians that hold these beliefs may be less likely to recommend certain treatments to blacks because they see it as “wasteful” (IOM, 1997, p. 173). These racial biases that lead to discrimination are often present at a subconscious level and are more prevalent when communicating with patients and families that are perceived to be from a different culture or race (Surbone, 2010, citing Sabin et al., 2009). Many of these disparities are traced to historic patterns of segregation and discrimination that were legalized in the past and unfortunately continue to have a negative impact today (IOMNA, 2002). Segregation, oppression, and violence against blacks were institutionalized as a result, in part, of the American elite and the judicial system defining who is black by the one-drop rule (Davis, 2002). Anyone who had a “single drop of black blood” was considered black by definition and consequently inferior (Davis, 2002, p. 5). This