Black and Blue. John Hoberman
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evaluated and placed on a waiting list or given a transplant.”111 These black patients had expressed a preference for undergoing surgery. Their doctors, for whatever reasons, did not always prefer to accommodate their wishes.
These reports make clear the rhetorical significance of the term “patient preferences,” which effectively removes physicians from the decision-making process, thereby exempting them from responsibility for whichever treatment choice is made. The other misleading function of this term is to endow black patients with an independence and a sense of security that not all of them are likely to feel in a modern hospital setting. A white physician who treats a black patient in 2012 may not realize that the patient's medical clock may be set at 1952 or 1922, depending on the legacy that medical racism has left in that person's family over many years. The patient's decision not to undergo surgery in the present may have been shaped by a traumatic past whose effects neither the doctor nor the patient understands. But the fact that the doctor does not grasp what is happening will not prevent the consequences of a misunderstanding.
The preceding analysis of medical rhetoric and vocabulary asserts that American medical authors have failed to produce an honest and accurate assessment of their own behaviors in the domain of race relations. The constant use of various euphemisms to gentrify race relations and envelope doctors' behaviors in a sanitizing jargon points to a deeply rooted resistance to self-scrutiny and real reform. The exceptions to this rule are few. M. Gregg Bloche calls the “overwhelming” evidence that “members of disadvantaged minority groups receive poorer health care than whites” a “bitter truth.”112 But this sharp acknowledgment of failure sounds a discordant note in a medical literature that has long been in denial about race matters. As three African American physicians pointed out in JAMA as far back as 1989, “the most likely reason for these inequalities is that physicians value black lives less than white lives.” Commenting on a JAMA article on racial inequalities in treatments for heart disease, they go on to call this study an exercise in evasion, since “racism is considered only briefly, lastly, and politely as 'socio-cultural factors influencing physician and patient decision making.'” They cannot understand why the authors “stopped shy of implicating racism. Their own article carefully documents the evidence in the medical literature.”113 More than two decades later, the medical literature continues to practice this sort of denial. The verbal evidence of this stalemate is the persistence of stultifying jargon. The alienation of white doctors from black patients is a problem of “patient physician race concordance.” Black patients may experience “less patient-centered” visits than white patients and hear a “less positive affective tone” when doctors address them.114
The medical literature thus remains in one sense an elaborate arrangement whereby white physicians are insulated from certain kinds of discomfiting information about the medical suffering of black people and from knowledge of how black patients or colleagues assess their professional behavior. The voices of black patients and physicians appear, infrequently, in newspapers.115 Black people's analyses of how white physicians behave in interracial encounters play no significant role in American medicine's halfhearted attempts to deal with its half-acknowledged race problem.
The effect of these publications about doctor-patient relationships has not been to promote the reform of medical training or to negotiate a new relationship with the black population. The actual result has been more publications of the same kind. There are no studies of how doctors actually think about their black patients, no inventories of stereotypes, few inquiries into racially motivated diagnostic errors, and no analyses of the transmission of racial folklore from one medical generation to the next. Apart from an occasional reference to the Tuskegee Syphilis Experiment, references to the history of medical racism in the United States are almost entirely absent. Editorial gatekeepers ensure that potentially discomfiting penetrations of the physician's private sphere do not appear in the professional literature. American medicine thus persists in the mistaken belief that it has left the world of racially inspired medical folklore far behind.
Deciphering the racial complexes of physicians in the medical literature of the post-civil rights era is difficult due to the obscurantist jargon medical authors use to take the sting, the pungency, and the menace out of race relations as they are acted out in medical settings. Sanitizing race in this way also serves to protect the privacy of doctors whose racial beliefs are officially regarded as humane until there is dramatic evidence to suggest otherwise. The sanctity of the private sphere within which physicians' thoughts and feelings shape their decisions derives from their traditional sense of autonomy. Physicians who acknowledge that racially motivated judgments can affect medical practice may challenge doctors' assumed right to privacy by advocating some kind of therapeutic intervention. “If we recognize our own negative racial attitudes,” David Levy wrote, “we should ask ourselves why we need them and then do something to effect personal growth and change. For psychiatrists who lack the empathy needed for work with all groups of people, psychoanalysis has been recommended to erase distorted perspectives concerning race or at least to enable them to become more aware of when their irrational attitudes might impede the treatment process.”116
THE PHYSICIAN'S PRIVATE SPHERE
A generation after Levy wrote these words, prescribing psychotherapy for racially troubled physicians remains an improbable and even exotic proposal for reform. An alternative to the status quo would be the systematic detection and exposure of racially motivated conduct by doctors—an option the medical profession has never embraced. The legal scholar Dorothy Roberts, who has written on the medical racism that has been inflicted on black women, has challenged the pretense of medical autonomy and argued that “doctors' ‘private’ moral dilemmas involving their patients are actually interpreted and resolved according to relationships of power in the larger society.” Highly trained and affluent physicians (or lawyers or professors) can, in fact, exercise illegitimate and unethical forms of power over their undereducated patients (or clients or students), white or black. Roberts's objective, therefore, is “to shatter the myth that the interaction between physician and patient is a private matter.”117
Resistance to the shattering of this “myth” of privacy is embedded in the medical profession, and is directly related to physicians' sense that professional conduct is independent of the larger social forces (such as race relations) that operate in the wider world outside the office. Most doctors, according to the physician and health policy scholar Troyen Brennan, “think a patient is best treated if the physician follows her personal and ethical code in dealing with sensitive issues…. Nor do most of my colleagues think that medical ethics should define a public role for physicians, or that health law and policy should represent moral challenges for physi-cians.”118 The problem is that many (and probably a majority of) physicians have not developed “personal and ethical codes” that would enable them to deal successfully with “sensitive issues” like race in a comfortable and competent way. Where, indeed, would the physician's “personal and ethical code” for racial encounters come from? Our social institutions do little to prepare any of us for race matters, and medical education does little to remedy this deficit (see Chapter 5).
The result of laissez-faire race relations in the medical world is an unregulated environment in which patients in general, and black patients in particular, hold the weaker cards. The executive vice president for medical affairs at a Long Island, New York, hospital defended this limited view of a doctor's accountability (and his own) in 1998 in the following terms: “The issue for us is to accept patients without regard to race, creed, color, national origin or ability to pay. After that, how the cookie crumbles is something over which we have little or no control and, I think, little or no responsibility.” This administrator had no plans to monitor the racial conduct of the physicians who practice medicine at his hospital, and he apparently saw no reason to do so. The consequences of this policy, according to Kathleen Gaffney, the Nassau County health commissioner, are predictable: “You get treated by what you look like. If you're black…the physician is less likely to take your symptoms as seriously, so you may not get the same response. There continue to be health care stereotypes in terms of minority patients being less compliant, they 'don't take their drugs,' and there is also a perception they are less motivated