Assessed from a distance, Australia’s healthcare system may seem to shine.

Contrasted with the near non-existence of subsidised medicine in the United States, and the increasing shortages of doctors and other specialists seen globally, Australia could be taken as providing healthcare at least a calibre above the rest. However, with a closer look, it quickly becomes apparent that one’s assessment of the ethical status of Australia’s healthcare system is one that is decidedly dependent upon the vantage point of the assessor.

When we narrow our scope and focus instead on the internal workings of the Australian system, holding it to a local, desired standard of performance, its ethical misgivings readily become apparent. If the role of a successful healthcare system is to provide equally for all, where illness, disability or socioeconomic status do not stand as features which reliably disenfranchise its users, then the current formation of our local system does not seem to ethically sparkle.

Dr Annmaree Watharow was a general practitioner for over two decades. She is a recent PhD graduate from the University of Technology Sydney where she completed her dissertation on the healthcare and hospital experiences of those who have dual sensory impairments. She has published works on topics ranging from improving communication within healthcare environments to fostering improved practice in research settings, along with personal testimonies on her experiences of living with deafblindness.

When I ask Dr Watharow what she takes to be the central ethical failure of our current healthcare system, she responds concisely:

“Parity of access to quality healthcare is the key ethical issue.”

If we agree that equal access is a central pillar to an ethical system of healthcare, we are required to understand who is currently being left out and why, in order to begin remedial work.

“Migrant populations, homeless, incarcerated, LGBTQI+, veterans, older Australians, Indigenous Australians, and people living with disability and chronic illness” are all social groups that Dr Watharow sees as belonging on the (not exhaustive) list of those who are directly and negatively impacted by the apparent partialities in contemporary healthcare systems.

Where there are losers, there are also winners – or, at the very least, those who remain comfortable in the current modes of national healthcare dissemination. When considering the broader Australian population, Dr Watharow suggests, “Multiple sections are disadvantaged, but you have a core group who are well positioned to leverage advantage. These are people with good income, good housing, good nutrition”.

Pre-existing social structures that both create and sustain sharp disparities in income, quality of housing, education and health work to negatively impact an individual’s wellbeing. These factors are oftentimes discussed as being ‘social determinants of health’, such that they directly affect a person’s risk of developing physical or mental illness. Dr Watharow importantly draws our attention to how those belonging to disenfranchised groups are subsequently more likely to be negatively impacted by facets of our social structure that reach far beyond the healthcare system.

“There are inadequacies in our social welfare, justice and recognition systems which fail these groups”, Dr Watharow explains. When considering current pensions and welfare allowances for example, it is apparent that some individuals have their health compromised long before they end up in a hospital bed. “The current funds don’t allow people to practice healthcare or good nutrition or have quality housing. All of these contribute to poorer healthcare outcomes.”

Evidently, assessments of the ethics of our healthcare system would be incomplete without an assessment of the broader society in which that system operates. Dr Watharow helpfully turns our focus to how broader, socioeconomic disadvantage necessarily breeds unequal access to and benefit from current systems of healthcare.

Better understanding these causal factors, which directly contribute to this inequality, usefully directs us towards finding pragmatic solutions, and Dr Watharow is clear in pointing out a pivotal step that is necessary to spur positive change: we need to provide a means by which the wide array of disenfranchised voices may articulate the intricacies of their own disadvantage.

“The lynchpin of the medical system should be shared decision making. For that to happen, everyone needs access, they need communication, and communication support if not able to communicate.” Ensuring the representation of marginalised voices in both research and political settings is a necessary step towards the shared decision making required for the construction of an ethical, inclusive healthcare system. If particular users of the healthcare system are silenced in their capacity to communicate their needs or experiences, inequality will be fostered.

Critically, creating the capacity for individuals to speak truth to the power is only the first step. “We need an attitudinal shift in how we treat those who are older, have a disability, or cognitive impairment. We need healthcare institutes to comply with the statues that exist on an international, national, and state levels that prohibit abuse, neglect, and violence, as well as promote healthcare.”

Dr Watharow emphasises that Australians, especially Indigenous Australians, living with disability are a key population who remain poignantly disadvantaged in the current healthcare system. Even with the construction of government services such as the National Disability Insurance Scheme (NDIS), these groups continue to suffer in the face of discriminatory social systems which stifle the capacity for their needs to be adequately heard across community, research, and political settings.

“I think the NDIS [National Disability Insurance Scheme] has severely short-changed First Nations peoples by not understanding that their disability experiences and needs are not the same as non-Indigenous. Disability is understood differently and there are major barriers to getting disability services to rural and remote regions. Added to this, many First Peoples need basic things like shelter, food, work; if you haven’t got the money for a bus fare to town you can’t go get assessed, if you haven’t got predictable housing how do you get home help?”.

Recognising the insufficiencies of social welfare schemes and the impact these have on practices of healthcare again draws our attention to the importance of addressing nationwide, systemic inequality in order to construct ethical systems of healthcare. Unfortunately, aiming to remedy broader social inequalities as a method to achieve equitable healthcare may appear a slow and arduous approach. Luckily, as Dr Watharow suggests, these ambitions need not be pursued in lieu of more targeted action.

“If we put in some basic work to expecting our health environments to be compliant with universal design principles and disability standards; if we expect our staff there to be aware, knowledgeable and compliant with accessibility and communication provisions (which are enshrined in legal statutes) and if we enforce these with audits, spot checks and evaluation of complaints, if we make it a condition of service that staff do yearly training and upskilling in providing equitable access and communication and care to PLWD [people living with disabilities], we can do so much!”

The process of constructing an ethical healthcare system in Australia requires both remedial and aspirational work. Currently, quality healthcare cannot be equally accessed by all. Understanding which groups face obstacles to access, and why, is a critical starting point for resolution. We require a commitment to ensuring individuals can communicate their needs and critiques of current models, and that these calls are heard and responded to. Concurrently, it must be demanded that pre-existing standards of care are reliably upheld and not entirely disregarded.

Critically, neither of these methods will be pursued if current attitudes toward particular members of our society remain engrained. As Dr Watharow offers, “a greater inclusion and tolerance of difference in all levels of society” is required if we are to garner the motivation required to remedy existing inequalities.

The solutions are multifaceted, slow, and likely expensive. But if we are committed to equality, both in systems of health and in our societies more broadly, the gap between those who can enjoy healthy lives, and those who cannot, should slowly close.