Unique Ethical and Practical Considerations in the Use of Behavior Contracts for Families of Minors and Minoritized Populations in Pediatric Settings

Responding Effectively to Disruptive Patient Behaviors

“…Behavior contracts may not be designed to discriminate, but any method for enforcing behavioral compliance has the potential to be discriminatory when staff judgment is involved in identifying which patients are difficult, and deciding when behavior contracts are implemented . Studies show that Black patients and families are more likely to have behavior contracts in place, which can be explained by implicit (or explicit) bias, particularly given the subjectiveness of the behaviors they target .…”

“…No one should have to tolerate verbal or physical abuse at work; health care institutions must develop effective, proactive, and ethical solutions to this complex and nuanced problem… Behavior contracts may not be designed to discriminate, but any method for enforcing behavioral compliance has the potential to be discriminatory when staff judgment is involved in identifying which patients are difficult, and deciding when behavior contracts are implemented. 2,4 Studies show that Black patients and families are more likely to have behavior contracts in place, which can be explained by implicit (or explicit) bias, particularly given the subjectiveness of the behaviors they target. 4,6,7 The chief equity and inclusion officer of Children's Minnesota, an urban hospital that serves a racially, ethnically, and socioeconomically diverse population, reconsidered the use of behavior contracts after realizing that they were disproportionately used against Black patients and families: "There are biases and misunderstandings at work in how behavior contracts have been handled…that continue to cause systemic and inequitable health outcomes for our Black patients and families."…”

“…2,4 Studies show that Black patients and families are more likely to have behavior contracts in place, which can be explained by implicit (or explicit) bias, particularly given the subjectiveness of the behaviors they target. 4,6,7 The chief equity and inclusion officer of Children's Minnesota, an urban hospital that serves a racially, ethnically, and socioeconomically diverse population, reconsidered the use of behavior contracts after realizing that they were disproportionately used against Black patients and families: "There are biases and misunderstandings at work in how behavior contracts have been handled…that continue to cause systemic and inequitable health outcomes for our Black patients and families." 5 Clinicians and health care staff must be protected from violence and abuse in ways that align with and honor the fiduciary responsibilities to patients and protect the rights of all.…”

“…Absent such evidence, health care institutions committed to evidence-based medicine and workplace safety might hesitate before using these contracts. When viewed alongside the ethical considerations, which have been extensively explored in the bioethics literature, we argue that the lack of supportive evidence generates an ethical imperative to reconsider their use altogether. Such reconsideration should include internal audits of how and when they are used, address the lack of institutional transparency and accountability about their use, and impose consistency and ethical safeguards.…”