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M. Gregg Bloche
excerpted Wrom: RWTQTIPWIGYOKSTTZRCLBDXRQBGJSNBOHMKH
in American Medicine, 1 Yale Journal of Health Policy, Law & Ethics
95-121, 95-97 (Spring 2001) (111 Footnotes Omitted)
Rarely has a piece of social science research received more attention
than the 1999 study by Kevin Schulman and others reporting large
differences in physicians' responses to identical heart disease symptoms
presented by black and white actors portraying patients. The 720
physician-subjects who participated in the study referred lower
proportions of African- American than white age and sex matched
"patients" for cardiac catheterization, a costly,
state-of-the-art diagnostic measure, even after the researchers
controlled for physicians' subjective impressions of disease likelihood
and severity. Critics quickly found errors in the authors' statistical
methodology--errors that exaggerated these racial disparities. The New
England Journal of Medicine, in which the article appeared, then took
the extraordinary step of issuing a partial retraction.
Yet publication of the Schulman study did more than any other single
event to put the matter of racial disparities in health and medical care
on the American public policy agenda--and to frame political discussion
of the topic. Hundreds of prior publications reported powerful evidence
of racial gaps in life expectancy, morbidity from various illnesses,
access to health insurance and services, and the clinical management of
disease. But the Schulman study's use of African-American and white
actors with identical scripts presented a stark picture of pure racial
bias, uncomplicated by the potentially mediating roles of educational
background, economic status, or other social cues. The study received
national media attention, and months later a congressional
appropriations report termed its findings "alarming." Report
language spotlighting the Schulman study accompanied federal legislation
funding an Institute of Medicine (IOM) inquiry into the scope, impact,
and causes of racial bias in American medicine. A variety of other
public and private sector initiatives targeted racial bias in American
health care as a topic for research, discussion, and intervention.
Racial disparities in health care provision that persist even when
researchers control for income, education, and health insurance status
are the primary focus of these initiatives. Efforts to understand the
reasons for these disparities have focused on psychological, social, and
cultural influences that affect providers' clinical judgments and
patients' expressed preferences. In this Article, I explore
institutional, economic, and legal factors that contribute to these
disparities. This contribution, which I contend is larger than
commentators on health care disparities typically acknowledge, occurs
through interaction between organizational and legal arrangements and
physicians' exercise of clinical discretion. Because these arrangements
are amenable to pragmatic intervention, they deserve close attention.
My focus in this Article is on racial disparities in medical care
provision--that is, on differences in the services that clinically
similar patients receive when they present to the health care system.
Racial disparities in health status, which is not greatly influenced (on
a population- wide basis) by medical care, are beyond my scope here.
Disparities in medical care access--potential patients' ability,
financial and otherwise, to gain entry to the health care system in the
first place, are also outside my focus. But I begin this Article by
putting the problem of racial disparities in medical care provision
within the larger context of disparities in health status and medical
care access.
In Part I, I concede: (1) that medical care is almost certainly less
important as a determinant of health than are social and environmental
influences, and (2) that inequalities in Americans' ability to gain
entry to the health care system probably play a larger role in medical
treatment disparities than do racial differences in the care provided to
people who succeed in gaining entry. I then briefly examine the moral
politics behind the appearance of racial disparity in health care
provision on the national policy agenda, ahead of disparities in health
status and medical care access.
In Part II, I consider the links between clinical discretion and
racial disparities in health care provision. I argue that pervasive
uncertainty and disagreement, about both the efficacy of most medical
interventions and the valuation of favorable and disappointing clinical
outcomes, leave ample room for discretionary judgments that produce
racial disparities. Neither existing institutional and legal tools, nor
prevailing ethical norms, impose tight constraints on this discretion.
As a result, provider (and patient) presuppositions, attitudes, and
fears that engender racial disparities have wide space in which to
operate.
In Part III, I refine this argument, pointing to a variety of extant
organizational, financial, and legal arrangements that interact
perniciously with psychological and social factors to potentiate racial
disparities.
Part IV considers the impact of the managed care revolution,
contending that its cost containment strategies both contribute to
racial differences in health care provision and create opportunities for
reducing some of these disparities. Part V closes with some
recommendations as to how health care institutions and the law might
respond pragmatically to racial disparities even as they pursue other
important policy goals. |
