A man with a beard and gray hair is in a hospital bed. Image by G.Go via Adobe Stock.
Yeseñia Sandoval is a biochemistry major with a minor in biotechnology and she is a 2024-25 health care ethics intern at the Markkula Center for Applied Ethics at Santa Clara University. Views are her own.
Let's begin with a story about Daniel, a Hispanic man that immigrated from Mexico, who struggles to find a good-paying job and lives in a low-income neighborhood. Despite financial challenges and being uninsured, Daniel does his best to eat healthy and becomes a regular church goer. He finds a home within the church community. Despite growing old with hardship, Daniel lived to 85. How is this possible? There are multiple hypotheses to explain the contradiction between the disadvantaged status of most Hispanics and their long life span. Research suggests that spirituality and religion have a strong correlation with life expectancy, which could be the explanation and should be integrated into holistic patient care.
Currently, in the United States non-Hispanic whites live to the age of 77.5, compared to Hispanics who on average live to 80. This nation is filled with a diverse population of people, with Hispanics representing 19.1% of the population, making it the second largest ethnic group. However, this community faces many challenges. Currently, they are the largest uninsured group in the United States, with 16.8% compared to 5.3% of non-Hispanic Whites. They have higher rates of unemployment at 4.5%, with a lower median income of $65,882. They are less educated, with 73.1% having high school diplomas and 20.4% possessing a bachelor's degree. Despite this, they often live longer than the average American. This phenomenon is known as the Hispanic mortality paradox.
What is the Hispanic Mortality Paradox?
The Hispanic mortality paradox helps explain how Hispanics often have better health outcomes and live longer, despite less frequent doctor visits, discussions of health concerns, and a poorer diet. Currently two theories provide explanations for this paradox. The first theory is “The Salmon Bias” where immigrants tend to return to their birth country once they are sick, retired, or need a job. The second theory is the “Healthy Migrant Hypothesis” where only the healthiest from the country tend to immigrate to a new country. There is no strong evidence that indicates that either explanation proves the paradox, as both appear to contribute without offering a complete answer.
One explanation that is worth mentioning is the “Barrio Neighborhood Advantage”. This is where immigrants tend to live in similar areas, providing a space of similar cultures and experiences, which can lower stress and anxiety. This emphasizes the importance of social relationships, which lowers diabetes, cognitive decline, and other chronic conditions. In this article, an additional explanation is offered through an exploration of the role that spirituality and religion may play in the Hispanic mortality paradox which requires rethinking how spirituality and health care coexist.
Spiritual Culture in Holistic Care Amongst Hispanics
Holistic medicine emphasizes treating the whole person through an understanding of social, psychological, familial, societal and ethical factors. Amongst these holistic approaches is an individual's spirituality. Spirituality is defined as the search for a meaning or purpose that transcends to a deeper understanding of life. In Hispanic culture, spirituality can be practiced with religion, however it's important to recognize that both can exist independently. According to Pew Research, 72% of Hispanics report a religious affiliation.
While religion and spirituality share similar practices such as prayer and meditation, they can influence health independently. Among Hispanics, research shows that placing a higher importance on religion and frequent religious prayer can lead to better coping and less stress as they provide coping mechanisms and comfort. Separately, an increase in spirituality has been associated with fewer deaths, better cognition, better self-reported health, and less mental health effects. Both spirituality and religion are associated with feeling less lonely and increase feelings of faith and hope. Religious and spiritual health may provide support that can improve a person's overall mental health. Mental health influences physical health as it can increase the risk of long-lasting conditions (i.e. diabetes, heart disease, etc.) This is important as spiritual and religious health can be a positive indicator of a person's mental and physical health.
Ethical Considerations for American Health Care System
The Hispanic mortality paradox suggests that the incorporation of discussions about religion and spirituality may lead to better patient outcomes and a more comprehensive understanding of the patient's overall wellbeing. Health care providers must develop cultural humility, which recognizes that they may not fully understand a patient's culture, but can still respect its values including religion and spirituality. The fact that this viewpoint was only formally acknowledged by the American Medical Association (AMA) in 2015 through an opinion piece is surprising. This delay reflects not only a gap in professional standards but a cultural hesitation within American society to openly engage with religion and spirituality in a professional setting.
Currently, 41% of Americans decide to avoid discussion of religion to avoid disagreement, suggesting reluctance toward these conversations. It is important to remember that promoting discussions about spiritual health is not about imposing one’s own views but about the recognition that spirituality can play an integral role in people's lives. The four main ethical principles held by physicians – beneficence, nonmaleficence, autonomy, and justice – are often only understood through a secular view excluding spiritual well-being.
In 2018, the AMA released a guide for physicians on how to incorporate discussions about spirituality and religion during care. This emphasizes that physicians have a duty to provide holistic care that respects the whole person including their spiritual self. According to the ethical principles of beneficence and autonomy, providers are obligated to respect a patient's right to self-determination and promote their well-being. When the norm for physician-patient interactions doesn’t include discussions about religion, patients who have religious beliefs are limited in fully expressing themselves. In other words, their autonomy is hindered. Failure to fully consider this aspect of care can prevent a physician from fully caring for their patient and breaking trust. Research shows that these topics are still being neglected in care. These neglects are detrimental to the quality of care patients receive and therefore, their trust in the health care system. If physicians fail to build trust, then those patients may be less likely to follow medical advice or adhere to treatment plans. This directly violates the principle of nonmaleficence, which is to do no harm.
Although this aspect of care is overlooked, Hispanics continue to experience longer lifespan. The Hispanic mortality paradox highlights a gap in medical education and training particularly in addressing holistic needs, despite increased efforts since 2018. When applying the ethical principle of justice, it becomes clear that the integration of spirituality into health care could be used to fight ongoing health disparities, including for other minority communities. Justice demands that all patients receive equitable, patient-centered care. This begins with establishing trust, openness from physicians, and focusing on the whole person.
The purpose of health care is to promote positive health outcomes and life longevity. Despite challenges in health care, the Hispanic community still lives long lives. Spirituality and religion likely play a role. Ultimately, physicians have an ethical responsibility to discuss spirituality and religion, if seen as beneficial. Health care institutions have an obligation to create a culture of respect and openness towards spirituality and religion in health care to promote inclusive and compassionate patient care.