Black and Blue. John Hoberman
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For example, the author of one of the studies of heart disease previously cited cautions that “racial variation in rates of coronary revascularization may have resulted in part from differences in the prevalence of disease, the severity of disease, and other clinical factors.”69 If heart disease occurs more often in one group than another, then that in itself might account for different numbers of procedures in the respective patient populations. Similarly, if the severity of a disease differs in blacks and whites for biological reasons—glaucoma, for example, is a more serious disorder in blacks than in whites—then different treatments may be appropriate. Determining whether the appearance of more (or more severe) disease in one racial group is due at least in part to biological factors remains difficult and controversial for reasons we will examine next.
RESISTANCE TO THE CRITIQUE OF RACIAL BIAS IN MEDICINE
American medicine has reacted ambivalently to the hundreds of studies that have documented racial disparities in health care. On the one hand, medical journals publish the reports that confirm the disparities, and these reports are sometimes accompanied by editorial commentaries that describe the disparities as intolerable and call for action to reverse them. At the same time, these medical authors have developed a rhetorical strategy that allows them to deplore racial health and treatment disparities without taking responsibility for them. Even the liberal white doctors who actually care about racial injustice in medicine have found ways to formulate their analyses of physician behaviors in such a way as to avoid threatening their own self-images and exposing the profession to critical scrutiny by outsiders.
Ambivalence about confirming the existence of medical racism has also been evident in the federal agencies responsible for monitoring and improving public health. In 1985 the Department of Health and Human Services (HHS) released its Report of the Secretary's Task Force on Black and Minority Health, documenting many health disparities. In 1999, Congress instructed the Agency for Healthcare Research and Quality (AHRQ) to publish an annual report, beginning in 2003, to document “prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations.” The first National Healthcare Disparities Report (NHDR) was released in 2003, the second in 2004, and a third (and more complete) report in 2005.70 The National Academies' Institute of Medicine issued a similar report in 2002.71 The chairman of the committee that wrote the report, a former president of the American Medical Association (AMA), commented: “The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming, but in developing strategies to reduce and eliminate them.” At the same time, the National Academies' news release, summarizing the implications of the report, made notable use of the exculpating rhetoric and euphemizing vocabulary alluded to previously: “The report says that although it is reasonable to assume that the vast majority of health care providers find prejudice morally abhorrent, several studies show that even well-meaning people who are not overtly biased or prejudiced typically demonstrate unconscious negative racial attitudes and stereotypes. In addition, the time pressures that characterize many clinical encounters, as well as the complex thinking and decision-making they require, may increase the likelihood that stereotyping will occur.”72
This is the standard medical liberal's interpretation of the individual doctor's racially motivated behavior. According to this account, the “vast majority” of medical personnel are committed antiracists; “well-meaning” people succumb to “unconscious negative racial attitudes and stereotypes” that are hidden from them and for which, therefore, they cannot be held responsible until they are made aware of them. The stereotyping of patients originates in external circumstances such as “time pressures” that exacerbate the already formidable challenges of “complex thinking and decision-making.” There is, of course, some truth to this interpretation, including the essential point that a person can be unaware of his or her racial attitudes and their consequences for other people. But this is also a children's book version of medical reality that has been sanitized to preserve the self-image of the medical profession. The racial goodwill of the “vast majority” of white practitioners is taken for granted. Their racially motivated behaviors originate in unconscious attitudes and hectic schedules that do not allow them to be their true and racially wholesome selves. The black patients who may have been subjected to racially motivated negligence are absent from a drama that is focused on the needs of its white dramatis personae.
A similarly evasive strategy is evident in the influential and expanding field of biomedical ethics, which has effectively taken a pass on the issue of medical racism. The fifth edition of the standard text, Beauchamp and Childress' Principles of Biomedical Ethics (2001), devotes exactly one and one-half pages to the “unfair distribution of health care based on race.” Its approach is entirely sociological; we are presented with the familiar data about lower black rates of cardiac surgery and organ transplantation and nothing on the psychology or possible misbehaviors of the individual physician.73 Here, too, medical professionals are exempted from scrutiny that might challenge their image as uniformly humane and impartial caregivers. Similarly, The Oxford Handbook of Bioethics (2009) includes nothing about race and medical ethics.
Despite its self-exculpating agenda, the liberal perspective on health disparities and medical racism is self-critical when compared with right-wing responses to criticism of the medical profession's treatment of minority patients. Resistance to even acknowledging the reality of racial health disparities can appear in state or federal agencies when the ideological winds in government are blowing in from the conservative end of the political spectrum. The deputy administrator for the Wisconsin Division of Public Health, Kenneth Baldwin, stated the following in 2001: “I'm not willing to say or place [sic] racism as a reason for [the] health disparity. I think it would be naïve to say that, when there is no one answer to the problem.” This official preferred to identify poverty as the explanation for differential health outcomes and suggest that race was irrelevant to higher rates of black morbidity and mortality.74
The same preference for nonracial explanations for racial health disparities came to public attention in 2004 when political appointees in the Department of Health and Human Services (DHHS) of President George W. Bush were found to have altered a federal report on health disparities based on the 2002 Institute of Medicine report. The original version of this report issued in July 2003 concluded that racial disparities are “pervasive in our healthcare system.”75 This finding was too much for DHHS conservatives, so the version released in December 2003 was edited to present a more upbeat interpretation of the data. For example, “A report by the special investigative division of the Congressional Committee on Government Reform found that the word ‘disparity,’ mentioned 30 times in the ‘key findings’ of the [initial] draft, was used only twice in the key findings of the final version.”76 M. Gregg Bloche, a physician and bioethicist who had served on the Institute of Medicine Committee, commented in 2004: “In playing down our conclusion, the rewrite broke with the great weight of scientific opinion…. By insisting that the AHRQ researchers treat the existence of racial disparities as an unproven hypothesis rather than an established premise for their report, those who ordered the rewrite imposed their politics on federal science.” The conservatives went so far as to demand that the AHRQ researchers do the virtually impossible—control for enormously complex confounding factors such as the effects of social class and education—or eliminate all claims about disparities from the report. When leaks from DHHS forced the DHHS Secretary, Tommy Thompson, to release the original and uncensored version, he called the initial release of the altered report a “mistake.”77
Why did DHHS conservatives want to suppress data about racial health disparities? M. Gregg Bloche pointed to their disdain for governmentsponsored social engineering and the related emphasis on personal responsibility: “A coherent vision motivated the proponents of the rewrite. This vision stresses the centrality of personal responsibility, both for our health and for our circumstances more generally. To call the rewrite's supporters racially insensitive oversimplifies matters.”78 The conservatives' other urgent priority was to suppress any claim that doctors were guilty of racially motivated misconduct. That is why the rewritten version, while acknowledging that “some socioeconomic, racial, ethnic and geographic differences exist,” also states the following: “There is no implication that these differences