Black and Blue. John Hoberman
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racist,” a health disparities researcher said in 1998. “Physicians have very busy worlds. The encounters [with patients] are quick. These are things that increase stereotyping.”98 One problem with the frequently invoked distinction between the overt and the subtle, quite apart from the standard disconnect from historical experience, is the idea that objectionable racially motivated behaviors announce themselves in the form of overt prejudice. The rhetorical effect of this claim is to exonerate the silent majority whose feelings about race remain inconspicuous. To be sure, these people may be influenced by “subtle stereotyping,” but this mental state is itself regarded as exonerating because the stereotyping is too subtle to be noticed by those who have fallen under its sway. The challenge of holding doctors accountable for their behavior remains deferred until that time when the entire situation will be better understood. A rationale for deferring the assigning of responsibility for racially unequal cardiac care appears in a 1993 New England Journal article:
The extent to which subtle or overt racism underlies racial differences in the use of cardiac procedures is unclear. We believe that inadequate health education, differences in patients' preferences for invasive management, delivery systems that are unfriendly to members of certain cultures, and overt racism all may play a part. Allocating responsibility more precisely will require studies that control for angiographic data and directly examine interactions between patients and medical professionals.99
Deferred along with the allocating of responsibility is the question of why the medical profession has done so little to promote the studies of “interactions between patients and medical professionals” that might get physicians to recognize the ways in which medical relationships involving blacks and whites can and do go wrong.
This portrait of the physicians' vulnerability to “prejudice” effectively exonerates them of responsibility, since denigrating or hostile motives are presumed to be absent. Even though they are filled with “moral abhorrence” at racial prejudice, physicians “may not recognize manifestations of prejudice in their own behavior.” Given this predicament, one might think that the authors would call for some sort of training to liberate doctors from their racial stereotypes. But they decline to do so, calling instead for more research, since the evidence linking stereotyping and prejudice to disparities in health care is merely “indirect.”
The sheer obfuscation and confusion the agnostic approach to disparities can cause are particularly evident at the end of a New England Journal article that attracted wide publicity following its publication in 1999. The notoriety of “The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization” resulted from its misleading presentation of statistical evidence that exaggerated its findings of physician bias.100 An unnoted irony of this media event was that a paper that infuriated some physicians by exaggerating findings of bias concluded with a version of the standard exoneration of physicians whose tangled jargon is in a class by itself:
Our finding that the race and sex of the patient influence the recommendations of physicians independently of other factors may suggest bias on the part of the physicians. However, our study could not assess the form of bias. Bias may represent overt prejudice on the part of physicians or, more likely, could be the result of subconscious perceptions rather than deliberate actions or thoughts. Subconscious bias occurs when a patient's membership in a target group automatically activates a cultural stereotype in the physician's memory regardless of the level of prejudice the physician has.101
Following the familiar distinction between “overt prejudice” and “subconscious bias,” the final sentence of this passage makes a point of dissociating physicians from their own racial bias. According to this psychology of prejudice, there is no relationship between the cultural stereotype that is “automatically activated” in physicians' memory and the “level of prejudice” they may harbor. Once again the minds of doctors are presented as playthings that are at the mercy of forces operating “automatically” outside them. Physicians “have” a “level of prejudice” in the same sense that they “have” other more innocuous traits for which they bear no responsibility. “Subconscious bias” serves as physicians' alibi not to be held responsible for their racially motivated behaviors.
Racially motivated feelings and behaviors on the part of physicians can also play a role in their decisions about whether medical treatments will be offered to patients, and whether those patients will feel inclined to accept treatments from medical personnel they may not trust. Black patients are frequently reported to be less willing to undergo “technologically intensive interventions” such as surgery. “Blacks with cerebro-vascular disease are more averse to the risks of surgery than whites and are more likely than whites to refuse coronary artery bypass surgery when it is offered. Similarly, blacks with end-stage renal disease are somewhat less likely than whites to want renal transplantation…. Black men with osteoarthritis perceived the risk of joint replacement to be higher, the rehabilitation longer and more painful, and the ultimate functional outcome less favorable than white men's perceptions…. Black patients appeared to fear perioperative risks of coronary artery bypass graft surgery more than whites did.”102 This reluctance to be operated on applies to a variety of procedures. “Blacks also report less confidence in the efficacy of knee or hip replacement, suggesting that lack of information about risks and benefits, compounded by a general distrust of the health care system, is a partial determinant of the observed lower operation rates.”103 Jeffrey N. Katz pointed out in 2001 that one source of these fears may be the fact that “the risks of mortality and complications following coronary artery bypass graft surgery are higher in blacks than in whites, even after adjustment for case severity. Referring physicians may communicate these local risk patterns to their patients.” For example, black physicians tend to be somewhat more pessimistic about the benefits of joint replacement operations than their white colleagues.104 White physicians may also doubt that kidney transplantation promotes the survival of blacks to the same degree as it does that of whites.105
The treatments black patients either prefer or avoid can have a great deal to do with beliefs or feelings of which white medical personnel may be unaware. Conspiracy theories and urban rumors about medical dangers have circulated in the black community for many years. Some African American patients have reported a widespread belief in the black community that being exposed to air during lung cancer surgery can make the tumor spread, causing some patients to refuse the surgery and to disbelieve physicians' assurances that this fear is unwarranted.106 African American patients can also be influenced by racial stereotypes in ways that prevent them from acting on their preferences. One study, for example, found that “black women were uncomfortable talking to physicians about menopause, fearing that they would sound unintelligent or mentally impaired, and were dissatisfied with the discussions when they did raise the subject with their doctors.”107
Many years passed before medical authors began to abandon the practice of invoking “patient preferences” as a convenient alibi for inferior medical care and to begin to talk candidly about the role that fear and distrust can play in these decisions. “Patient ‘preference’ for less intensive treatment,” Katz noted, “may in fact represent resignation to the perceived status quo—that interventions are unavailable, unaffordable, ineffective, or unduly risky—even if those perceptions are not accurate.”108 But the greatest degree of candor about how preferences work appears, not in the medical literature, but in newspaper coverage of racial health disparities. It was Newsday, not the New England Journal, that in 1998 published the following commentary by Ed Hannan, a professor and chairman of the Department of Health Policy, Management and Behavior at the School of Public Health at the State University at Albany: “One of the things alleged by those who say that there are truly not racial differences [in treatment] is that blacks tend to turn down procedures that have been offered to them. But what we found, essentially, is that the physician did not recommend the surgery.”109 Dr. Robert Gaston, a transplant surgeon at the University of Alabama in Birmingham, the largest transplant center in the United States, told Newsday that doctors dealing with poor African Americans in particular “will come up to a person and say something like, ‘You really don't want a transplant, do you?’”110 A 1999 study concluded that: “Among the patients in our study