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Rene Bowser
Excerpted from Rene Bowser, Racial Bias in Medical
Treatment, 105 Dickinson Law Review 365-383, 371-381 (Spring 2001) (71
footnotes)
To understand the dynamics that contribute to racial bias in medical
treatment, this essay looks at clinical decision making from an
institutional perspective. The striking replication of racial
disparities across numerous medical diagnostic categories and in nearly
every type of health care setting strongly suggests that more powerful
forces are at work than the unconscious racism of some White physicians.
An institutional analysis is helpful for two principle reasons.
First, it identifies and clarifies the symbiotic relationship between
actors who discriminate, on the one hand, and specific organiza-tional
practices, norms and processes that perpetuate discrim-ination, on the
other. Moreover, an institutional analysis addresses the issue of effect
and practice, rather than intent. Institutional actors may harbor no
racial prejudice but, nevertheless may help perpetuate organizational
patterns and processes that become self- sustaining and discriminatory.
Medical institutions, I suggest, carve up the world into mutually
exclusive domains of Black and White, each possessing distinct meanings
for physicians. These institutions express and recreate generally
negative understandings about Black patients. Institutional bias in
medicine is an unseen, self-sustaining force. This essay turns to New
Institutionalism to explain how these institutions work.
New Institutionalism gives the term "institution" a
distinct technical meaning; it
refers to self-perpetuating patterns and practices made in reliance on
taken-for-granted background knowledge, rather than organizations. These
patterns and practices rely on and are antecedent to unspoken rules and
unexamined background knowledge--the "natural facts of life"
that any member of the organization knows.
Institutions in this technical sense are largely invisible and
typically rely on an analogy to nature so as not to be seen as a
contrived social arrangement formed to privilege one set of competing
interests over another. Moreover, institutionalized, patterns and
behaviors are reproduced because individuals can not conceive of
alternatives, or view alternatives as unrealistic. Finally, institutions
suffer from amnesia; the present is like no other period and, therefore,
present patterns and practices share no link to the same activities
performed in the past.
Not all institutions are racist. New Institutionalism defines
institutional racism as those self-perpetuating patterns and practices
made in reliance on taken-for-granted background knowledge about race
that serve to lower a particular racial group's status.
What, then, are the institutions in medicine that produce and
reinforce racial disparities in medical treatment? The first
institu-tion, I argue, is the practice of conducting comparative medical
studies of Blacks and Whites to understand the poorer health outcomes of
Blacks. I refer to this institution as
racialized research.
A. Racialized Research Makes African-Americans Sick
Researchers conduct comparative medical and epidemiological studies
to explain observed differences in health outcomes between Blacks and
Whites. This work uses race as a variable to explain differences in the
incidence of disease among the "races", variations in health
outcomes, differences in survival rates from all types of diseases,
disparities in responses to treatments, and differences in the etiology
or pathways of disease.
Collectively, racialized research constructs Black patients as
degenerate in relation to the White norm. Blacks are viewed as
biologically different, and this work frequently infers that there
exists a genetic basis for disease in Blacks not found in Whites. Based
on these differences, racialized research reports that Blacks respond
more poorly to treatment, are more likely to die from expensive invasive
medical procedures, and possess more virulent diseases and tumors.
Further, racialized research suggests that Blacks are genetically
disposed to a host of chronic diseases, including hypertension, obesity,
prostate cancer, low-birth weight infants, left ventricular dysfunction,
nicotine addiction, asthma, and Alzheimer's disease.
Numerous papers published in the modern medical literature also
reference race as an independent risk factor related to survival from
prostate cancer, breast cancer,
lung cancer, brain cancer, colon cancer and esophageal cancer. Moreover,
Blacks are viewed as having less favorable prognoses than White patients
for other medical conditions such as Hodgkin's disease.
From a cultural perspective, Blacks are similarly viewed as
degenerate in relation to the White norm. Racialized research suggests
that Blacks are less likely to comply with medical treatment, less
likely to be knowledgeable about their disease, less likely to view the
disease as diminishing their quality of life, and less likely to be
involved in promoting their own health.
Thus, as a general matter, racialized research collectively fosters
the background understanding that "these sorts of people don't do
well." Black difference and inferiority take on a rule-like status
and constitute the unquestioned backgroundknowledge used by researchers
studying Black health. As I argue below, this unconsidered background
knowledge influences whether and how physicians treat Black patients.
The current search for biological difference is undeniably linked to
the past. Historically, comparative medical studies were intentionally
undertaken to identify biological differences in Blacks in order to
stamp these individuals as inferior. The search for difference was
synonymous with the search for inferiority. Medicine provided much of
the theory and data that correlated differences in skin color, hair
texture, physical appearance, and behavior
between Blacks and Whites to confirm the superiority of Whites. Indeed,
medicine played a crucial role in providing "scientific"
justifications for slavery and Jim Crow laws.
While current methodologies are arguably more sophisticated, the
institution of searching for difference is the same. Fullilove puts it
this way:
All to often, when race is found to explain a significant portion of
the variation in some health outcome, little is done to explain the
meaning of the association. The result is that medical researchers act
as if there were inherent--if undefined--differences between racial
groups that, once signaled, require no further explanation. In an odd
way, there is little difference at times between our modern science and
the discredited practice of using science and medicine to justify
slavery in the antebellum South: each assumes that racial differences
are of unquestioned importance.
This is not to say that medical research is monolithic and that
current practices have gone unquestioned. Thoughtful researchers have
asked for a justification as to why "race" is so frequently
used as a key variable in medical and epidemiological research, when
only a small percentage of the variations between humans in total
genetic material can be attributed to differences in "race",
and why so many diseases are linked without proof to this small amount
of diversity.
Race is a social construct, not
a scientific reality. Geneticists have further shown that the
differences between classically described racial groups account for only
10 percent of genetic variation (much of which is due to genes
associated with skin color). This figure is only slightly greater than
the 6 percent variation that exists between nations, such as the
populations of France and Spain, or between different tribes in Africa.
Furthermore, greater genetic variation exists within the populations
categorized as Black and White than between these populations.
Consistent difference in one gene between populations is extremely
rare and accounts for only a tiny proportion of total potential
variation. The usually cited case, sickle cell anemia, is the unusual
case. Such a single gene abnormality can be handled on its own merit
without reference to dubious racial categories. Genetic variation in a
single gene, such as that for sickle cell anemia in Blacks or Tay Sachs
disease in Ashenazi Jews, does not imply that populations that possess
that gene will vary in important ways for other health conditions. Such
a false analogy would suggest that White Australians who possess a
particular gene for skin cancer are predisposed to other diseases.
The recent sequencing of the human genome provides additional
evidence that race has little biological meaning. As one scientist has
pointed out:
In view of the sad part that race and ethnicity still play in most
societies, concerns that genetic analyses of different human populations
could be abused are appropriate. Fortunately, from the few studies of
nuclear DNA sequences, it is clear that what is called 'race', although
culturally important, reflects just a few continuous traits determined
by a tiny fraction of our genes. This tiny fraction gives no indication
of variations at other parts of our genome. Thus, from the perspective
of nuclear genes, it is often the case that two persons from the same
part of the world who look superficially alike are less related to each
other than they are to persons from other parts of the world who look
different.
Racialized research is also complicated by the problem of perception.
In nearly all racialized research published in the United States, the
comparison group has been the majority (White population). Far from
being a neutral category, this approach consolidates Whites as the group
with which all "others" should be compared; it also disregards
research that demonstrates the value of studying variations in health
among, say, African-Americans, as opposed to always comparing them with
White Americans.
The use of the white body as the point of comparison is neither
neutral nor objective. Whiteness is relational, and its use as a
scientific variable is inherently laden with meanings about differ-ence,
deviance and superiority. Whiteness
as a variable obscures the heterogeneity among White populations and
maintains White race consciousness. It also allows researchers to ignore
the social, economic and political advantages of being White in the
United States, and the implications of such White privilege for health.
As Osbourne and Feit have put it: "The social consequences of
racial comparisons in medical publications may depend more on the
perceptions that adverse comparisons reinforce in society than on the
accuracy of the data, the intent of the authors, or the correctness of
their interpretations."
After years of studying differences between Blacks and Whites, there
is little evidence that such research has paid positive dividends to
Blacks. As one prominent radiation and medical oncologist has noted:
"Thus far the designation of race as a major health care variable
has not resulted in the improvement of care for anyone. Those who have
benefited most from such practices have been health care
researchers."
In the face of such criticism, there must be reasons why the findings
and conclusions of racialized research fill the pages of the most
prominent medical journals. The explanation is complex, but at its
simplest level, comparative research is self-sustaining because the
scientific truth obtained from prior research, that Blacks are
different, is accepted. The a priori sense of rightness of this
background knowledge is unquestioned because it is founded on an analogy
to nature. In the minds of some, it seems "natural" that people
who have different genes for phenotypic traits like skin color should
also possess different genes for physiological function.
Thus, to understand the inferior health status of Blacks in this
country, researchers are institutionally channeled to look for the
genetic difference that causes a susceptibility to disease and a lower
survival rate once the disease has manifested itself. There are
differences among the races. But, institutional amnesia causes them to
ignore or forget the fact that, historically, racial construction did
not occur in a vacuum, but in the context of a dominant ideology,
perceived economic interests and psychological necessity.
Racialized research is maintained and perpetuated because many
researchers can not imagine plausible alternative non-biological
explanations of the inferior health status of African Americans. In the
19th century, progressive voices that argued that the poor health status
of Blacks was due to racism, rather than innate racial differences, were
silenced. Today, the institution of racialized medical research
continues this intellectual apartheid; "White physicians who focus
on racism as opposed to cultural peculiarities or the genetic basis of
disease are likely to be considered both as not 'real scientists' and as
dangerous."
Starting with a belief in Black biological differences and some
statistical knowledge, a Black-White difference can almost always be
found. Research grants and evidence
of "hard" clinical research ability and productivity are vital
in terms of prestige, recognition and promotion. Racialized research is
a major industry, and showing difference enhances the researcher's
status. As Kaufman and Cooper have pointed out: "Questionable
techniques may be retained if they provide what is believed to be the
'right' answer, and in a society with deeply ingrained beliefs about
racial differences, a scientific confirmation of these differences is
the expected, and therefore the 'right', answer."
B. Bedside Bias and Racialized Research
Now the other half of the argument. This essay suggests that
physicians rely on the findings and conclusions of racialized research
in treating African-American patients. The result is a pattern or
practice of less treatment. I refer to this institution as bedside bias.
In deciding whether or how to treat a Black patient, a physician's
decision is guided by the institutional understandings about Black
health. Clinical practice is increasingly evidence-based. The "best
evidence" is generally studies from the biomedical literature that
study treatment outcomes, survival rates, prognoses and the like. The
dubious findings and conclusions of racialized research provide some of
the "best evidence."
In a recent discussion on race and medicine, I asked a group of about
forty fourth-year medical students
whether they would recommend heart bypass surgery for a Black patient,
given the fact that the "best evidence" points to a
substantially lower survival rate for Blacks from this procedure.
Although certainly not a scientific survey, several students stated that
they would use such evidence in making a treatment decision based on a
belief in the validity of the survival data; others stated that because
their education is heavily evidence-based, they are expected to rely on
such information. Black students, however, stated that they would not
rely on this "best evidence" and, instead, would evaluate the
patient on an individualized basis.
Reliance on the taken-for-granted medical knowledge about Black
health also saves time and lowers transactions costs. Patient race is
one of the leadoff indicators in clinical rounds and medical
presentations. Physicians use race because they believe that it contains
useful information, rather than being an unscientific, socially
constructed concept. In this regard, Steven Caldwell argues that race
"serves as little more than a 'jog' to the memory of busy
clinicians."
White physicians spend less time with Black patients and frequently,
do not include Black patients in clinical decision making. By relying on
taken-for-granted background information, physicians may miss clinically
relevant information, or assume the presence or absence of genetic or
cultural factors that, in fact, may or may not be present. A physician
might rule out autoimmune hepatitis
in a Black patient presenting with symptoms of fever, malaise, weakness,
nausea and abdominal distress because racial-ized research indicates
that this form of hepatitis is associated with specific
histocompatibility antigens, which are less prevalent in Blacks.
Instead, the patient may be diagnosed with another form of hepatitis and
given the incorrect treatment.
Of course, the cultural context of the physician/patient relationship
is another important consideration. Patient race is associated with
physicians' assessment of patient intelligence, feelings of affiliation
toward the patient and beliefs about patients' likelihood of substance
abuse and non- compliance. Moreover, physician education contributes to
the formation of medical stereotypes. Group interaction and
socialization into the medical profession sustain and reinforce these
views.
The cultural context of the physician/patient encounter is indirectly
linked to the institution of racialized research. The use of race as a
scientific variable medicalizes difference; that is, it legitimates and
naturalizes racial categories. The reliance on cultural stereotypes in
the physician/patient encounter can be reconceptualized as institutional
racism because it treats race as an unquestioned, natural part of the
social order, and creates false and unconsidered good/bad dichotomies
that lower the health status of Blacks.
Physicians, therefore, are not
understood simply as unbiased agents of science who display affective
neutrality and objectivity toward all patients. Indeed, assumptions
about a disease can vary based on the patient's "race." As
Harris argues, "[b]ackground assumptions that shape how the body is
formally or informally categorized constitute its meaning for
physicians."
Many of these background assumptions are formed from physician
socialization and a reliance on the findings of racialized research. The
utility of a given procedure is often decided a priori, without an
individualized assessment of the patient's condition. It is known that
these sorts of people don't do very well. Writing almost a century ago,
W.E.B. Dubois made a similar observation: "We must not forget that
most Americans answer all queries regarding the Negro a priori, and that
the least the human courtesy can do is listen to the evidence. |
