by Kayhan Parsi, J.D., Ph.D.
“To be ignorant of what occurred before you were born is to remain always a child.” (Cicero)
“Fight the Power” (Public Enemy)
Recently, our medical school hosted Dr. Linda Rae Murray to give a talk on structural racism and medicine. A former president of the American Public Health Association, Dr. Murray gave a powerful presentation on the history of racism in the United States and its lingering impact upon health disparities. In one of her more provocative slides, she graphically conveyed the long history of racism toward African Americans in the United States (before and after the founding of the republic). For 250 years, legalized slavery existed. After a brief period of Reconstruction, institutionalized racism persisted for another 75 years during the Jim Crow era. During the civil rights era of the 1950s and 1960s, civil rights legislation was finally passed. We have now been living for nearly 50 years in a post-civil-rights era (a mere fraction of the overall history recounted by Murray). Today, racial discrimination is clearly illegal. We even have a black President. Yet structural racism persists. Why is that?
Many factors are at play here. Our schools are de facto segregated based on where families live (as Danis, Wilson and White point out, “In some areas, there is more segregation than during the Jim Crow era”). One’s ZIP code has a profound impact upon health outcomes. And, as the authors also point out, “These patterns are not the result of chance.” This reflects the view of Paul Farmer, who argues that the social inequities of the world are not the product of accident or random events. Rather, they are the fruits of an ideology that oppresses certain groups because of their race (a social construct) or social status. (Farmer himself relates the old joke: “What is the definition of a liberal? Someone who believes all the bad things that happen in the world stem from accidents”).
Danis, Wilson, and White do the bioethics community a great service by highlighting the lengthy history of structural racism in the United States and its lasting and pernicious effect on the present day. Such a historical analysis belies the initial assertions of Mayor Rahm Emanuel of Chicago, who claimed that the officer who killed Laquan McDonald was simply a “bad apple” (he later reversed his view). A deeper historical analysis undercuts the “bad apple” theory; we are all complicit in broader structures that maintain and reinforce racist structures and practices. So kudos to Danis, Wilson, and White for highlighting the history behind our structural racism. What we see today are not random events, nor the result of a few “bad apples,” but rather reflect a deeply racist history in this country that was reinforced by the laws and social structures that existed for centuries.
The question posed to the community of bioethicists is—what can we do to address racism and racist violence? Danis, White, and Wilson claim that a concern for social justice is at the heart of our enterprise. Indeed, Beauchamp and Childress elevate justice in its importance in their estimable Principles of Biomedical Ethics (“Policies of just access to health care … dwarf in social importance every other issue considered in this book”). Danis, White, and Wilson go on to argue that our skills in scholarship and philosophical analysis, ethics consultation, teaching, policy, empirical research, outreach, and training can contribute to better addressing racism and racist violence. Of course, many of these skills are not unique to bioethicists—many academics share skills in scholarship, teaching, and empirical research. Public health professionals are also expert in outreach and training. In fact, public health as a field has done much more than bioethics in addressing many of these concerns. In contrast to public health, bioethics is a Johnny-come-lately to the table. Still, there is hope for our field.
Although Baker lauds the work of Danis, White and Wilson, he nonetheless believes bioethicists can make contributions in this area “without exceeding the bounds of their expertise” (or becoming philosopher kings, in the words of Weddle in her commentary. A case in point is the series of articles that Baker co-authored with other scholars for journals such as the Journal of the American Medical Association and the Journal of the National Medical Association. Such scholarly work forced the American Medical Association (AMA) Board to publicly apologize about its racist practice of excluding African American physicians. Although such scholarly work is not activist per se, it did have an almost immediate effect on a traditionally conservative organization such as the AMA. Similarly, Lisa Fuller calls for a more activist bioethics that will change the attitudes, beliefs, and practices of health care professionals by focusing on implantation intentions, decreasing time pressure, and increasing accountability through continued monitoring.
Others, such as Grzanka, Brian, and Shim, call for an intersectionality in bioethics, recognizing that racism is one of many −isms that oppress and marginalize groups and individuals. Classism is one −ism that is widely practiced in health care and in society at large. For instance, physicians are free not to treat individuals who are on Medicaid. This may not reflect individual classist views but does reinforce structural classism.
An example of intersectional work is the work done by Mark Kuczewski. In his commentary and his own work, he highlights the de facto system of apartheid we practice by excluding undocumented immigrants who are members of the community and contribute, yet cannot obtain higher education. Again, these practices are reinforced by laws and regulations that exclude undocumented immigrants from gaining admission to medical schools, obtaining loans, and securing residency slots. Despite the advances made by schools such as Loyola University Chicago in admitting undocumented students, Kuczewski makes it clear that policies that rest on executive orders are on shaky ground and can be easily eliminated by a future administration.
So, how are we to move forward? If we want to eliminate structural racism, we have to change the structures. As Rattani states, “The bioethics discipline lacks a firm presence in HBMSs [historically black medical schools].” This is a curious state of affairs, considering the role of race in such ethics abuses such as Tuskegee or the case of Henrietta Lacks. There should be flourishing bioethics programs at all of the four HBMSs. Moreover, leadership in bioethics should strive to be more diverse and inclusive. The American Society for Bioethics and Humanities has never had a president of color. As Danis, Wilson, and White state, we need to cultivate more leadership opportunities for people of color in the field of bioethics.
Lastly, as mentioned by Ho and Kuczewski, the way ethicists are paid will greatly shape the way they address issues related to race. Clinical ethicists are typically paid by their hospital employer and lack the academic freedom of their colleagues working in educational settings. Will such individuals take on the mantle and pursue such issues? As Sodeke states, working toward social justice and against racism requires some level of moral courage. How much of it will depend upon each individual.
But perhaps a better way to support such work is to ensure that moral courage is not the responsibility of one person or individual but is rather the mission of the organization. Thus, working toward social justice and against racism is embedded in our structures and reflected in the work of all individuals working in such structures and institutions. Such norms become internalized institutionally and individually and are not seen as heroic—rather, they’re the ordinary moral obligations of everyone. That’s my hope.