Black and Blue. John Hoberman
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pervasiveness of the oral tradition raises an important question about doctors' racial beliefs: Do the racial attitudes of physicians differ from those of the general population? Recent sociological findings indicate that while “whites have largely abandoned principled racism…they have not necessarily given up negative racial stereotypes” or “negative sentiments and beliefs about African Americans.”35 The prominent black sociologist William Julius Wilson reported in 2009: “The idea that the federal government 'has a special obligation to help improve the living standards of blacks' because they ‘have been discriminated against for so long’ was supported by only one in five whites in 2001, and has never exceeded support by more than one in four since 1975. Significantly, the lack of white support for this idea is not related to background factors such as level of education and age.”36In short, a large majority of the white population is either unwilling or unable to see African American problems in their historical context and has only limited knowledge of what the black experience has been like.
The research I have done for this book confirms that physicians share the racial attitudes of their fellow citizens. Indeed, their intimate involvement with medically afflicted black bodies and minds may even create and intensify feelings about the racial differences they perceive. There is, then, no evident reason to assume that doctors feel greater sympathy toward or possess a greater understanding of African Americans that most whites do. On the contrary, it is probable that many doctors, like police officers, are exposed to more than their fair share of extreme and unattractive behaviors of the troubled and the indigent, a disproportionate number of whom may be black. These experiences do not produce racial goodwill. Consequently, as one African American physician commented in 1990: “The problem is not that medical providers are ethically deficient compared with the public, it is that we are no longer any better. Our ranks include racists and virtually every other variety of impaired citizenry.”37
Medical authors have occasionally wondered about how they as a group compare to the general public regarding racial prejudice. “As health professionals,” two physicians wrote in 2002, “we need to become aware of any deep-seated attitudinal biases that parallel those of the general public and the media and confuse our best clinical intentions.”38 A year later, H. Jack Geiger, who has been disinclined to acknowledge the existence of systemic medical racism, noted “the persistence and prevalence of racist beliefs and discriminatory behaviors in contemporary American society,” and reluctantly conceded that doctors are not “fully insulated from attitudes toward race, ethnicity, and social class that are prevalent (though often unacknowledged) in the larger society.” At the same time, Geiger's assertion that “most physicians” possess a “conscious commitment to anti-discriminatory principles” appears to claim that the racial enlightenment of doctors exceeds that of the general public.39 It is worth noting that Geiger's emphasis on doctors' relative immunity from prejudice aligns him with racism-denying conservatives who have directed caustic attacks on medical liberals such as himself. From the conservative perspective, even taking seriously the possibility of systemic medical racism expresses an unwarranted and offensive lack of confidence in the (white) medical profession as a whole.
It is important to recognize the role that political conservatives have played in promoting the “halo effect” that protects this powerful, and predominantly white, professional community. It has been an axiom of political conservatism, and its traditional emphasis on white male authority, that physicians are beyond criticism regarding the racial attitudes that a majority of white Americans share. The conservative social policy analyst Byron M. Roth, for example, found “questionable the charge that blacks suffer disproportionate health problems because racism taints American medicine. Doctors and nurses are among the least likely candidates upon whom to pin the label of bigotry.”40 The psychiatrist and conservative ideologue Sally Satel has made a public career of promoting the mistaken argument that “political correctness is corrupting medicine.”41 In fact, and as this book demonstrates, the medical profession is a predominantly conservative professional community that has tended to resist “politically correct” norms and policies.
THE MEDICAL LIBERALS
As is so often the case in American policy debates, the conservative attack on “politically correct” medicine has not been matched by a comparably vigorous response from the “liberal” side. The grand document of medical liberalism is Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2003), a publication of the prestigious Institute of Medicine, the health arm of the National Academy of Sciences.42 In his contribution to this volume, H. Jack Geiger portrays doctors as the helpless victims of a stereotyping process that is “automatically triggered and operates below the level of conscious awareness.” Once again medical racism remains for this author a hypothesis rather than a documented reality: “[F]urther research is necessary,” he says, “to clarify whether sociocultural and educational incongruity between providers and patients translates into misunderstandings about patients' preferences and expectations, and to evaluate the extent to which stereotyping, discrimination and bias exist in the hospital setting.”43 The fact that these hypothetical misunderstandings and stereotypes had already been thoroughly documented inside and outside of the medical literature appears to be unknown to this author. Only ignorance of the history of medical racism in the United States can account for naïveté on this scale. A similar essay by a team of medical ethicists repeats Geiger's claims about “well-meaning” medical personnel and the unfortunate consequences for minority patients of “clinician errors” that cannot be blamed on doctors who are the victims of their own “unconscious” biases.44
And what about the effects of the medical school experience on students' attitudes toward patients who are resented for one reason or another? “One of the few areas of universal agreement concerning students' development,” Academic Medicine reported in 1996, “is that medical training can make students and residents more cynical and insensitive.”45But not when it comes to race at Harvard Medical School, these ethicists report. Among the medical students they observed, “political correctness appears to be the normative order in public discussion. Medical students with whom we spoke note they never hear overtly negative racist comments in the hospital or among classmates. This sensitivity is new to the late twentieth-century generation of medical students and faculty in our study area.”46 Yet in the same year the Institute of Medicine volume appeared, another author in Academic Medicine who studied other medical students cites “a derogatory term widely used by students and faculty members to refer to patients from the skid row area of the city.”47 A decade earlier, Academic Medicine had observed that medical students sometimes saw patients as “sources of frustration and antagonism—evocatively recast as 'hits,' 'gomers,' 'geeks,' and 'dirtballs.' They become 'the enemy,' with students feeling justified in their use of negative labels and corresponding behaviors.”48 Are Harvard medical students really immune to the racist banter more realistic observers have noted? The credulity of the Harvard ethicists, who take at face value medical students' assurances about their generation's racial enlightenment, perfectly complements Geiger's dogged resistance to the idea that physicians should be held responsible for racially motivated decisions that derive from unconscious impulses.49
Medical liberals who adopt the exculpatory approach to physician responsibility are in no position to contest the claims of conservatives who argue that medical racism is a minor issue or does not exist at all. The Unequal Treatment report first issued in 2002, the product of a committee chaired by a former president of the American Medical Association, Alan Nelson, is a thoroughly moderate document. The strongest language in Dr. Nelson's speech to the Institute of Medicine on March 22, 2002, reads as follows: “Bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care. While indirect evidence from several lines of research support this statement, a greater understanding of the prevalence and influence of the processes is needed and should be sought through research.”50 Here, as elsewhere, medical liberalism was still treating the effects of “stereotyping, prejudice, and clinical uncertainty” as hypothetical, and there is the usual call for additional research, an implicit claim that the medical status of African Americans—and the behavior