Our nation seems to be at another crossroads of ideas and identities that could perfect or divide our union. The effort to minify and destroy Diversity, Equity and Inclusion (DEI) efforts across industries, through disinformation and legislation, has created distress and disengagement in many organizations across industries 1. In public and private sectors, anti-DEI campaigns have been waged to rollback expressed commitments, if not actual progress, to be more demographically diverse, ensure workplace climates are respectful and supportive of all employees’ ability to thrive, demonstrate forward and inclusive thinking about the populations served by the organization, remove barriers to access services, growth, or resources, etc. and more. Many organizations have capitulated, seemingly out of fear of targeted attacks or to avoid accountability for their statements of commitment 2.
Fred Hutch Cancer Center is steadfast in advancing our DEI strategy in order to accelerate the mission of curing cancer through research and compassionate care. Our determination is rooted in an honest recognition of our context as an American institution, a complex understanding of DEI history, purpose, and practice, and our obligation to an ethic of care. This abstract outlines our reasons for sustaining commitment to this work, the journey to inclusive excellence at this moment.
Diversity, Equity and Inclusion concepts
Diversity, Equity and Inclusion are three distinct but related concepts. They can be defined and framed in several ways; definitions for common reference are offered here.
- Diversity refers to individual and social differences in a specified context. Each of these categories of difference can have varying weights or saliency, informed by the sociohistorical context.
- Equity refers to principles of fairness that are operationalized through access, advancement, and outcomes. Equity demands a structural response to differing needs of individuals and groups.
- Inclusion refers to the process and goal of engaging differences in ways that reinforce the inherent value and full participation of everyone within the context.
These foundational definitions are starting points to more profound, challenging, inviting, and rewarding understandings of these concepts. Further, deeper comprehension and application of these concepts and principles is where the opportunity for a healthier, happier society lies.
Several societies around the globe, at various time periods recognized, explored and pursued fundamental conceptions of diversity, equity, and inclusion in various ways. From ancient civilizations like Egypt, Greece, and Rome to the nations of modernity (Jaiswal, 2024). Over millennia, diversity concepts have become increasingly complex; for example, evolving from various families and tribes to “ruler” and “ruled,” nations, ethnicities, and classes to very broad sets of identity groups we recognize today. The number and diversity of differentiated social groups were shaped by the types of civilizations — from early to colonial, imperial, post-imperial, to globalizing societies (Targowski, 2010). For our purposes, we will focus on the globalizing civilization that is the democratic republic of the United States of America and our national struggle to form “a more perfect union” (Constitution for the United States of America).
The writers of the Declaration of Independence (1776) and the framers of the Constitution of the United States (1787) sought to establish an independent nation whose government is representational and the political minority are protected. In seeking independence from British colonial rule, they also articulated concepts of liberty, justice, and individual pursuit of happiness — important concepts and aspirations in DEI work today. Juxtaposed with the system of enslavement of Africans and the mass killing, forced displacement, and systematic cultural destruction of Natives, the framers sought to advance these ideals as both reason for their own rights and posterity, and to express the ambitions of a new nation. Rooted in the expressed values and framing of the American Experiment, principles of diversity, equity, and inclusion are indispensable, even constitutive of American democracy; and our nation’s pursuit of them is reflected in the work that DEI as a practice is derived from and the progress that DEI pursues.
Decades of effort to increase opportunities
The field of Diversity, Equity and Inclusion was born from the need for all business and employment sectors to respond to legislation that sought to end discrimination and provide access to opportunity — the American dream. While the earliest federal actions to address discrimination occurred in the defense industry, with President Franklin D. Roosevelt’s 1941 Executive Order 8802 to prohibit racial discrimination and President Harry S. Truman’s Executive Order 9981 that desegregated the armed forces, it was President John F. Kennedy’s Executive Order 10925 (1961) that explicitly introduced the term “affirmative action” to treat government contracted employees “without regard to their race, creed, color, or national origin.” However, it was the historic Civil Rights Act of 1964, Title VII in particular, that made it unlawful for businesses to discriminate based on age, gender, national origin, race, and religion (Office of Labor-Management Standards website) with the Americans With Disabilities Act following in 1990 and inclusion of sexual orientation and transgender status added to Title VII protections in 2020. During these slow decades of federal change, individual states and municipalities adopted their own protections for various groups. DEI practitioners and organizational practices continued to develop alongside meeting new policies and the spirit of legislative action to not only end discrimination but also develop inclusive workplace and educational cultures conducive to employment and academic success.
In health care specifically, the Civil Rights Act, including Title VI which prohibits discrimination in programs or activities receiving federal funds, impacted the operation of hospitals and health care facilities toward greater diversity and equity for the workforce and patients. Two decades later, in response to the Heckler Report’s (1986) investigation of health inequities, the federal government’s formation of the Office of Minority Health in 1986 advanced formal DEI practice to another level. However, like the broader DEI journey, health equity has much earlier origins — even to the 1800s; and its modern conception has been shaped by governmental actions and policy interventions (Yao et al., 2019). Today, much of this work is centered on analyses of the social determinants of health and actions to combat their negative impact (Braveman & Williams, 2011).
The ethic of care
The legal and business cases for DEI are both helpful for the development of effective DEI programs. The legal case for DEI helps support the eradication of discrimination, and the business case supports buy-in across corporate organizations (Martinez, 2020). Yet, these cases, though quite strong, are always evolving; profits go up and down and legal compliance methods remain hotly contested. DEI needs a different if not an additional core that holds the causes of DEI together. Fred Hutch centers our efforts on something more immutable for our mission to find cures and deliver the highest quality of compassionate care to those who are suffering: the ethic of care.
It is well documented that there are inequities in health care access and outcomes (Bauchner, 2015; Smith, 1998; Williams & Cooper, 2019) as well as disparities in cancer research and treatment (Morris et al., 2010; Williams et al., 2022; Jackson, 2023). Meanwhile, Black, Indigenous and Latine physicians, who are more likely to serve in communities most impacted by health inequities, remain underrepresented at only 11.1% of all physicians. There is an urgent need to both train and retain physicians from minoritized communities. Further, medical training can be improved with more inclusive content as well as affirming, rather than abusive, experiences and environments in which students can thrive in their education.
Our attention to these issues, as well as an active (even affirmative) lawful practice to treat them, are the foundations of our care. Drawing from Fisher and Tronto’s (1990) four phases of care, our ethic of care is core to our DEI program, which expresses what we care about, who we care for, and how we practice caregiving and care receiving as a community of care practitioners.
We care about …
Honoring the humanity in every individual and community is the hallmark of our DEI strategy. It begins with the recognition of self-evident truths — all human beings are equal, with unalienable rights to life, liberty, and the pursuit of happiness — as the Declaration of Independence proclaims. We consider these truths along with the formal codes that guide health care organizations or institutions that work with human subjects — namely the Council for International Organizations of Medical Sciences guidelines, Department of Health and Human Services regulations, the Helsinki Declaration and the Nuremberg Code — to lead us in right doing. Right doing takes responsibility for judgment to act in ways that facilitate positive and healthful impact. Central to these guidelines is the responsibility to help and not to harm, an idea attributed to Hippocrates.
We care for …
The principle of safety is an ethic of care, without which no healthcare organization or human subjects research organization can rightfully operate — for the treatment of cancer, AIDS or any disease. Hence, it is our obligation to limit the risk of harm to our patients, potential patients, colleagues, partners, communities, etc. Our DEI strategy engages policies, practices, and people in a focused effort to reduce harm and protect or improve health holistically; this includes social dimensions. Our strategy is a thoughtful, scholarship-informed, and evidence-based intentional effort to reduce historic and contemporary societal harms and as much as possible prevent future harms. As a health care organization that centers our understanding of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organization), we must be engaged through DEI values, principles, and practices that stretch us, but do not harm us.
We engage caregiving and care receiving
History has shown that barring people from their self-evident rights to life, liberty and the pursuit of happiness is not only unhealthy but destructive — individually and collectively. Therefore, we make the concerted effort to remove barriers and implement initiatives that advance opportunities to do good. Lawful strategies that cultivate demographic diversity in our workforce empower innovation, build community trust, and prepare for the future of our country and the anticipated cancer burden in our region. Lawful strategies that foster inclusion reaffirm a sense of belonging and respect among the workforce and within the patient-provider relationship, generate compassionate care, and advance excellence. Strategies that pursue equity invite us to pursue and develop available talent that will benefit our mission with greater concordance between patient and provider, state population and our workforce. Further, our research and treatment seek outcomes that benefit every community and provide health access for generations.
Principles and practices of Diversity, Equity and Inclusion are literally matters of life and death. They are also about the ways in which we express, manage (use or abuse) and respond to power. It is our obligation and mission to pursue health, healing, and life beyond cancer. DEI is an investment in life and the power to heal.
