Almost 80% of indigenous Australians say that they have experienced racism in the health system. There is deep mistrust of a system that was instrumental in the removal of indigenous children from their families until the 1970s. There remain significant differentials in indigenous health outcomes vis-à-vis those of other citizens.

In response, in March 2018, the national Nursing and Midwifery Board released new Codes of Conduct for nurses and midwifes. These front-line health professionals are required to practice in ‘culturally safe and respectful’ fashion which means knowing how one’s ‘own culture, values, attitudes, assumptions and beliefs influence their interactions with people and families, the community and colleagues’. Ultimately, and most significantly it means avoiding ‘bias, discrimination and racism’ in one’s practice.

The falsification of these requirements, which are set out in less than one of the Codes’ 19 pages, to suggest that white nurses and midwives are required to ‘acknowledge their white privilege’ before treating an indigenous patient, even to the point of delaying life-saving treatment highlights the prevalence of race in contemporary public discourse.

The allegation, made under the guise of the objective journalism of Sky News and the Daily Telegraph appeared, in fact, to be political agitation in favour of ‘bias, discrimination and racism’. One could see how racism may contribute to ill-health and how as the Commonwealth itself admits:

Aboriginal and Torres Strait Islander people who have experienced discrimination are more likely to have high levels of psychological distress, to drink alcohol at harmful levels and to take illicit substances than those who have not. They are also less likely to trust the police, the local school, their doctor or their local hospital.

Health care is a matter of citizenship; a question of who is entitled to equal consideration in the receipt of public services and who is not. Reactions to the nurses and midwifery codes show how and why.

Professional workers have considerable discretion in their work; discretion over who to treat first and over who to treat with the what quality of care. Professional health work is not robotic. It is the outcome of human judgements about needs and entitlements. If official policies of respect, inclusion and equality of care can be undermined through public agitation, it follows that they can be undermined, or conversely enhanced, in the clinical setting. Indeed,

Public policy is not best understood as made in legislatures or top-floor suites of high-ranging administrators, because in important ways it is actually made in the crowded offices and daily encounters of street-level workers.

From one, perspective stereotypes and prejudices mean that indigenous patients have a lesser entitlement to care; a lesser belonging as citizens. From another, nurses and midwives have the professional agency and obligation to improve outcomes by caring for all people with equal skill and dedication.

Discussions of race in public policy are discussions of citizenship. They are debates about who belongs to a society and who does not. They are debates about the terms of belonging; who is really a citizen and who is not?

Liberal citizenship is grounded in the presumption that all members of a society enjoy equal capacities and entitlements. No one has a lesser claim to healthcare or its determinants than any other. For nurses and midwives, it is only the patient ‘and/or their family [who] can determine whether or not care is culturally safe and respectful’. Agency, in this respect, belongs to the patient; the indigenous patient as much as any other. On the other hand, citizenship becomes a negative determinant of health when it is structured to give some people greater political voice than others. Perhaps when it gives some citizens access to national television to present their opinions as uncontested fact.

The Codes do not refer to ‘white privilege’. They do not refer to privilege of any kind, but to professional capacities to work in ways that are effective and that are respectful of all people. Privilege is relevant only when one argues that some people are entitled to respectful care and others are not. The Codes are statements of liberal equality; recognising that clinical care is not ideologically neutral.

However, the discussion raised by Sky News and the Daily Telegraph shows that the question of what it means for an indigenous person to be a fundamentally equal liberal citizen is contested. It is a question of great moral and practical importance. It impacts on the healthcare that people receive and how associated policy debates are framed.

The discussion shows why money alone cannot ‘close the gap in indigenous disadvantage’. Money does not determine ideological positions. It does not determine the relative worth that a nurse or midwife attaches to one patient over another.

If citizens are to share the same capacity for effective health care, it is important that health’s political determinants are taken into account, including the political values that nurses and midwives bring to their work.

A society that needs to debate the merits of a professional body instructing its members to avoid biased, discriminatory or racist practice is not surprisingly one that has wide differentials in health outcomes across population groups.