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Vernellia R. Randall
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I am a registered nurse and a family nurse practitioner. I have a master's degree in nursing. I practiced nursing for 15 years in Alaska and Washington. I write and work in the area of health care law. I understand the health care system and the legal system . . . I am African American and trust the health care system to work in ways that ultimately will harm my people. (1)


Many people are surprised at the level of distrust of the health care system held by African Americans. However, fear and distrust of the health care system is a natural and logical response to the history of experimentation and abuse. The fear and distrust shape our lives and, consequently, our perspectives.(2) that perspective keeps African Americans from getting health care treatment, from participating in medical research, from signing living wills, and from donating organs. That perspective affects the health care that African Americans receive. This fear and distrust is rarely acknowledged in traditional bioethical discourse. 

Some bioethicists question the existence of a "uniquely" African American bioethical perspective. (3) They maintain that since the values and beliefs held by African Americans are also held by other oppressed groups, such as Native Americans, there is no African American perspective. However, these traditional bioethicists miss (or ignore) an important point: perspective is merely a subjective evaluation of the relative significance of something--a point-of-view. (4) Thus, to acknowledge an African American perspective, it is not necessary that African American values and belief systems be entirely different from others. 

It is faulty to assume that any group shares exactly the same value system with other groups. For example, Americans do not have one ethical perspective. Rather, race, class, and gender modify the commonality of the American experience. Different groups have had different experiences that, at a minimum, modify the dominant American perspective, if not replace it with an entirely different value structure. For African Americans, the combination of slavery, segregation, and racism have given us a different set of "intervening background assumptions about such essential bioethical concepts as personhood, bodily integrity, the moral community, fulfilling lives and utility." (5)

As a subculture of the American society, we have experienced something that others have not. The unique combination of slavery, segregation, and racism have caused us to develop not only different behavioral patterns, values, and beliefs but also different definitions, standards, or ordering of values. Furthermore, even where there is little difference in value systems and perspectives, there is a difference in the normative application of bioethical principles. For instance, there is no question that the principles of autonomy, beneficence, nonmaleficence, and justice have not been applied to African Americans in the same manner as European Americans. 

In the "Poplar Tree Narrative" Dr. Dick, a conscientious physician, applies the prima facie principles of beneficence, autonomy, and justice in such a way that castration of his black male patient is construed as a morally justifiable act, in substance and as a procedure . . . . [It kept the male] from getting into "trouble" . . . . [It made the male] . . . a better slave. . . . [He protected the male patient's autonomy] by getting what he construes to be [the patient's] informed consent. (6)

The apparent principles of Eurocentric bioethics are "embedded in a cultural matrix that encodes them with meaning." (7) The reality of bioethics is that ideas, such as autonomy, choice, beneficence, justice, and informed consent, are grounded in perspective and cultural context. (8) Perspectives are based, in part, on class, race, and gender experiences. The experiences of poor people are different from those of rich people; those of African Americans are different from European Americans, Native Americans, Hispanic Americans or Asian Americans. Experiences differ for women and men. Furthermore, rich people, White people, and men have more power than poor people, African Americans, or women. Power also affects experiences. A group's perspective reflects both cultural context and power or status differentials. (9)

But what then forms the basis of the African American perspective? (10)  Certainly, African American culture has acquired a significant part of its roots from the continent of Africa. For us, that means a belief system that includes a humanistic orientation, (11)  a focus on both personal and social responsibilities, (12)  and a high value placed on community belonging. (13)  To the extent that bioethical discourse and practice do not incorporate these values, they do not reflect the values of the African American community. (14)

However, African Americans' distrust of the health care system is based on more than a lack of certain African-based values. Our distrust is the direct result of our unique cultural birth in America. The African American culture is uniquely American. In some ways, African Americans, like Indians and Eskimos, are native Americans; that is, as a culture, African Americans exist only in America. African Americans are a blend of all the races of the world. (15) The dominant racial basis for our group is a blend of features from many African tribes. The most prominent influence on African American culture has been its past (and present) experiences of slavery, segregation, and racism. These African American experiences are clear evidence of cultural context, power, and status differentials which have resulted in a distrust of the health care system. This historical distrust is reinforced through current, continued, and ever-present institutional racism. (16)  These experiences fuel the basis for African American distrust. (17) 



FN1. My distrust of the health care system is typical of a belief held in the African American community: "I believe that the AIDS virus was developed in government labs for the purpose of controlling black folks." Annette Dula, African American Suspicion of the Healthcare System Is Justified: What Do We Do About It?, 3 CAMBRIDGE Q. HEALTHCARE ETHICS 347, 347 (1994) (citations omitted). "[M]any black Americans believe that AIDS and the health measures used against it are part of a conspiracy to wipe out the black race." The AIDS 'Plot' Against Blacks, N.Y. TIMES, May 12, 1992, at A22. "There's still so much fear and trepidation about what happened in Tuskegee, and it fuels the distrust blacks have of public health." Cheryl Clark, The Ghost of Tuskegee, S.D. UNION & TRIB., Jan. 28, 1996, at D14. "Behind the facade of big hospitals, many African Americans can only see one big medical experiment." Carol Stevens, Research: Distrust Runs Deep; Medical Community Seeks Solutions, DET. NEWS, Dec. 10, 1995, at A12 (quoting Vernice Anthony, Senior Vice-President of the St. John Health System, who has seen the "paranoia"). 

FN2. See generally Barbara A. Koenig & Jan Gates-Williams, Understanding Cultural Difference in Caring for Dying Patients, 163 W.J. MED. 244 (1995) (asserting that experiences of illness and death, as well as beliefs about the appropriate role of healers, are profoundly influenced by cultural background); Clark, supra note 1, at D14; Cynthia Hubert, African Americans Breaking Silence on Reality of AIDS, SACRAMENTO BEE, Jan. 2, 1996, at A1 (reporting that the inherent distrust among African Americans of the public health system results in people not accessing the system); Carol Stevens, Churches Preach the Gospel of Good Health, DET. NEWS, Dec. 11, 1995, at A1 (reporting that the lingering distrust of medical institutions has made it difficult for doctors to convince African Americans of the importance of screening tests); Stevens, supra note 1, at A12 (reporting concerns of African Americans about participating in medical research and screening tests); Sharon Voas, Aging Blacks Sick, Scared Past Abuses, Tradition Keep Them From Clinic, PITT. POST-GAZETTE, Aug. 27, 1995, at B1 (reporting failure of aging African Americans to seek care because of fear of doctors, of the haunting memories of shoddy hospitals for "coloreds" they were relegated to as children, and of being used in medical experiments). 

FN3. Tom L. Beauchamp, Response to Jorge Garcia, in AFRICAN-AMERICAN PERSPECTIVES ON BIOMEDICAL ETHICS 67, 72 (Harley E. Flack & Edmund D. Pellegrino eds., 1992) (maintaining that there is nothing particularly ethnic about the African American perspectives, since Native Americans may be as disposed to them as African Americans). 


FN5. Leonard Harris, Autonomy Under Duress, in AFRICAN-AMERICAN PERSPECTIVES ON BIOMEDICAL ETHICS 133, 134-35 (Harley E. Flack & Edmund D. Pellegrino eds., 1992) (discussing autonomy and health care as they relate to African Americans). See generally CECIL HELMAN, CULTURE, HEALTH AND ILLNESS (1995) (defining medical anthropology and discussing its impact on health and disease issues); CHARLES TAYLOR, MULTICULTURALISM AND "THE POLITICS OF RECOGNITION" (1992); Marjorie Kagawa-Singer, Diverse Cultural Beliefs and Practices About Death and Dying in the Elderly, in CULTURAL DIVERSITY AND GERIATRIC CARE: CHALLENGES TO THE HEALTH PROFESSIONS (Darryl Wieland et al. eds., 1994) (recognizing that differences exist in the way cultures experience and express death and dying); Celia J. Orona et al., Cultural Aspects Of Nondisclosure, 3 CAMBRIDGE Q. HEALTHCARE ETHICS 338 (1994); P.V. Caralis et al., The Influence Of Ethnicity And Race on Attitudes Toward Advance Directives, Life-Prolonging Treatments, and Euthanasia, 4 J. CLIN. ETHICS 155 (1993); Nancy Adler et al., Socioeconomic Inequalities In Health: No Easy Solution, 269 JAMA 3140 (1993) (considering mechanisms through which socioeconomic status affects health); Judith Barker, Cultural Diversity-- Changing The Context Of Medical Practice, 157 W.J. MED. 248 (1992) (reporting on the need for more clinical information to assist in the medical care of indigenous, as well as immigrant groups in America); Margaret Lock, The Concept Of Race: An Ideological Construct, 30 TRANSCULTURAL PSYCHIATRIC RES. REV. 203 (1993) (arguing that the health and well-being of visible minorities will continue to suffer as long as decisions are based on race and ethnicity); Arthur Kleinman & Joan Kleinman, Suffering And Its Professional Transformation: Toward an Ethnography of Interpersonal Experience, 15 CULTURAL MED. & PSYCHIATRIC 275 (1991) (discussing the plight of Chinese society and its cultural experiences); Ladson Hinton IV & Arthur Kleinman, Cultural Issues and International Psychiatric Diagnosis, in INTERNATIONAL REVIEW OF PSYCHIATRY 111 (Jorge Alberto Costa e Silva & Carol Nadelson eds., 1993) (analyzing the differences between relativists and universalists and their views of a single psychiatric nosology); ARTHUR KLEINMAN, PATIENTS AND HEALERS IN THE CONTEXT OF CULTURE (1980) (examining methods of healing throughout various cultures). 

FN6. Edmund D. Pellegrino, Response to Leonard, Harris, in AFRICAN-AMERICAN PERSPECTIVES ON BIOMEDICAL ETHICS 150, 151 (Harley E. Flack & Edmund D. Pellegrino eds., 1992); Harris, supra note 5, at 133-48 (telling stories, including the 'Polar Tree Narrative,' involving the application of biomedical principles in a way that disadvantaged African Americans). 

FN7. Pellegrino, supra note 6, at 151. 

FN8. Harris, supra note 5, at 133-35. 

FN9. Annette Dula, Yes, There Are African-American Perspectives on Bioethics, in AFRICAN-AMERICAN PERSPECTIVES ON BIOMEDICAL ETHICS 193, 194 (Harley E. Flack & Edmund D. Pellegrino eds., 1992). 

FN10. Marian Gray Secundy, Response to Kwasi Wiredu, in AFRICAN-AMERICAN PERSPECTIVES ON BIOMEDICAL ETHICS 99, 101 (Harley E. Flack & Edmund D. Pellegrino eds., 1992) (citing MECHAL SOBEL, TRABELIN' ON: THE SLAVE JOURNEY TO AN AFRO-BAPTIST FAITH 219 (1988)) (explaining that many West African world views used consensus to coalesce into African American culture). 

FN11. Humanistic belief is one that focuses on the importance of the human being over all else. "[W]hat is good in general is what promotes human interests." Kwasi Wiredu, The Moral Foundations of African Culture, in AFRICAN- AMERICAN PERSPECTIVES ON BIOMEDICAL ETHICS 80, 81 (Harley E. Flack & Edmund D. Pellegrino eds., 1992); see also Secundy, supra note 10, at 103. 

FN12. With a clear sense of individual responsibility comes an equally strong sense of the social reverberations of an individual's conduct. Thus, "[t]he primary responsibility for an action, positive or negative, rests with the doer, but a nontrivial, secondary responsibility extends to the individual's family and . . . to the . . . community." Wiredu, supra note 11, at 83-84. 

FN13. High value related to community belonging is based on a strong belief that all human beings deserve or ought to be helped. "Human beings . . . at all times, in one way or another, directly or indirectly, need the help of their [community]." Id. at 89; see also Secundy, supra note 10, at 103. 

FN14. Secundy, supra note 10, at 102; see also Cheryl J. Sanders, Problems and Limitations of an African-American Perspective in Biomedical Ethics: A Theological View, in AFRICAN-AMERICAN PERSPECTIVES ON BIOMEDICAL ETHICS 165, 167-70 (Harley E. Flack & Edmund D. Pellegrino eds., 1992). 

FN15. Most African Americans have parents, grandparents, or other ancestors who are not only of African descent, but also of European American, Asian American, Hispanic American, and Native American descent. My own family history is typical. On my maternal side, my grandmother's parents were Cherokee and African. My grandfather's parents were Italian and African. On my paternal side, my ancestors were all African. 

FN16. Dula, supra note 1, at 347-57. 

FN17. Id. 


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Professor Vernellia R. Randall
Institute on Race, Health Care and the Law
The University of Dayton School of Law
300 College Park 
Dayton, OH 45469-2772
Email: randall@udayton.edu


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