Black and Blue. John Hoberman
way [emphasis added].”79 Like the medical liberals, these medical policy conservatives were deeply invested in protecting the image of white physicians. This required them in turn to make the absurd claim that physicians are somehow immune to the effects of racial prejudice. In reality, a doctor who was incapable of falling into “moral error” would have to be a godlike creature. It is this element of hard-bitten denial that separates the obdurate conservative from the medical liberal whose ideas about the physician's intrinsically benign temperament are less extreme and are more open to correction on the basis of evidence.
One critic of Secretary Thompson's decision to release the original health disparities report was Dr. Sally L. Satel, a psychiatrist who specializes in the treatment of drug addiction and is affiliated with the conservative American Enterprise Institute. “Secretary Thompson succumbed to political pressure that was applied by members of Congress who are identified with ethnic causes,” she charged.80 The idea that racial health disparities do not originate in prejudice or injustice has been a fundamental premise of the ideologically driven views on race and medicine that Satel has published over many years. While conceding that some “lingering bias” may persist in the medical system, Satel's position is that “many race-related differences in health care are not what they seem.” Physicians and public health professionals who see racism in medicine are “indoctrinologists” who demonstrate a “stubborn reluctance to acknowledge that each person has some responsibility for preserving his or her own health— an attitude that threatens to reverse the gains made by public health in the past century.” She opposes any federal spending on research that is based on the idea that racism might affect African American health. Finally, she argues that racially differential treatment of whites and blacks results in part from anatomical differences between the races that disadvantage black patients.81 In summary, Satel's argument against what she regards as politically correct medicine amounts to a comprehensive defense of American physicians against the idea that racially motivated behaviors play any significant role in their relationships with black or other minority patients.
MEDICAL LIBERALISM AND THE MEDICAL LITERATURE
The conservative exculpation of physicians differs from the medical liberal's version in that the liberal analysis of physician behavior is more open-minded, far more concerned with ensuring social justice, and somewhat more willing to expose doctors' behavior to critical scrutiny. Still, the liberal consensus that has emerged over the last two decades almost always gives physicians the benefit of the doubt. These authors assume that American physicians are simply too conscientious to be capable of racially discriminatory diagnosis and treatment. They find it implausible that doctors would be as capable of absorbing and acting upon racial folklore as other people are.
The medical literature's response to overwhelming evidence of racially biased (and potentially deadly) behaviors has thus combined two strategies. On the one hand, there are the hundreds of peer-reviewed reports of racially differential diagnosis and treatment. At the same time, the presentation of these data employs a rhetoric of alibis, euphemism, and denial.82 The purpose of these rhetorical strategies is to demonstrate that, regardless of what the statistical evidence says about their behavior, American physicians are not “racists” who require reformation or public exposure. Many self-exculpating formulations of this kind have appeared in the medical and public health literatures, including a recent proposal that “racially based clinical stereotypes” are merely “cognitive 'shortcut[s]' busy clinicians may use to help order their world.”83 Here again we see “time pressure” invoked as a mitigating factor in the event the doctor employs racial stereotyping. This is not to deny the real pressures that HMO-mandated assembly-line medicine inflicts on busy physicians. The problem is that the hectic schedule is invoked to deemphasize the racial stereotypes that may be affecting clinicians' judgment when they encounter black patients. The significance of this terminology lies in the discomfiting details it leaves out and in the alibis it presents to the reader: Physicians who practice racially biased medicine are not themselves racists, but are simply too busy to behave more carefully. They are distracted rather than negligent or hostile. Racial bias is presented as an impersonal phenomenon for which doctors do not bear individual responsibility.
A major failing of the medical authors who have addressed the issue of medical racism in the medical literature is their lack of interest in the history of medical racism itself. Scientists' habit of relying on the most recently published work has come at the price of ignoring the history of medical thinking that has preceded and often influenced later thinking about race. Some physicians have thus acquired a naïve view of the history of race relations within the profession. Here, for example, we encounter the (white) physician who suggests in 1997 that African Americans' “lack of trust in the medical establishment may have originated with the disclosures about the Tuskegee syphilis study”—as if the racial misconduct of white physicians had somehow begun in 1972.84 The overt racism displayed by American medical authors in JAMA and other medical journals up until the Second World War appears to be unknown to the great majority of medical authors. This historical ignorance has in turn had a profound effect on the capacity of physicians to even imagine that doctors might behave in racially biased ways for which they might be held accountable.
Another obstacle to acknowledging the role of race in medical practice is a disproportionate emphasis on the complexity of the origins of racial disparities and how much about them remains unknown. The truisms that result from this sort of agnosticism distract readers from what is or should be known about racial factors but was apparently unknown to the authors who profess ignorance. The coauthors of a study of racially unequal treatment for heart disease, for example, wrote in 1989 that “we need to understand more about the complex interaction between physician and patient” that leads to inequality of medical treatments.85 In this case the tautological assertion that we need to understand more about what we don't understand obscures the more salient point, which is that critical analyses of “the complex interaction between physician and patient” had already appeared in the medical literature. In 1973 JAMA published David Satcher's observations on the racially insensitive conduct of many physicians and medical students he had watched interacting with black patients.86 In 1979 the Annals of Internal Medicine published John Eisenberg's seminal article on “Sociologic Influences on Decision-Making by Clinicians.”87 In 1985 Pediatrics published David Levy's examination of “White Doctors and Black Patients: Influence of Race on the Doctor-Patient Relationship.”88 To be sure, these prescient essays and a few others were buried among thousands of other communications in the medical literature with which they competed for attention. (The African American-edited Journal of the National Medical Association was then, and remains today, essentially ignored by the medical community and the news media.) The larger point is that these publications demonstrated a keen awareness of what the medical literature would eventually come to euphemize as “communication problems” between doctors and their patients. So it was, in fact, possible to recognize and think systematically about these problems before the flood of publications on racial health disparities began in the late 1980s.
What is most striking in retrospect is how impervious the medical literature has remained to the essential observations and recommendations that appear in these “early” publications, all of which postdate the civil rights era. The irony is that physicians' lack of interest in understanding their own professional behavior in its social context, which is one of Eisenberg's basic points about how doctors see themselves, has played a key role in keeping detailed and accurate accounts of black-white medical relationships and the effects of biomedical racial folklore out of the medical and public health literatures. “Physicians often object,” Eisenberg notes, “to being asked questions relating to professional and social factors, especially religious affiliation and social class origin. This denial of social influences is not limited to medical clinicians,” since even clinical psychologists tend to believe in their own invulnerability to social and cultural factors.89 Removing doctors from their social context offers the additional benefit of preserving the privacy of professional conduct. The absolute right to professional autonomy (and the authoritative judgments this implies) thrives in isolation from challenges to physicians' conduct toward patients who may or may not be satisfied with the doctors' manner or medical recommendations. Many years ago,