Black and Blue. John Hoberman
they believed the black patient was less likely to be critical and to express dissatisfaction or to question procedures. Most white physicians interpreted the master-servant relationship as a good doctor-patient relationship. Their patients were ‘happy.’”90 Keeping the doctors “happy” depended on their being unaware of how their ostensibly submissive black patients might actually feel about them.
Socially progressive medical liberals also participate in the strategy of denial through an inability or unwillingness to see medical race relations in their historical context. Seeing the Tuskegee scandal as a unique and temporary blemish on the honor of American medicine, they are likely to have little or no idea of how their predecessors judged and treated “the Negro patients” they encountered. Contemplating the possibility that the racial health disparities they found so “disturbing” might be due to “racially discriminatory rationing by physicians and health care institutions,” H. Jack Geiger commented: “We do not yet know enough to make that charge definitively.”91 In fact, Geiger's New England Journal editorial, titled “Race and Health Care—An American Dilemma?” (1996), is the prototype of the medical liberal response to racial health disparities. On the one hand, Geiger confronts the documented disparities and offers none of the conservative alibis that purport to explain them. But he simply cannot bring himself to believe “definitively” that his medical colleagues and the institutions to which they belong are capable of “racially discriminatory” professional behavior. Here, too, we see an important consequence of historical ignorance or naïveté. For either Geiger is unaware of the various forms of medical racism that were rampant in American medicine during the first half of the twentieth century, or he believes that racially motivated conduct on the part of American physicians was somehow abolished by civil rights legislation and the unofficial rules of political correctness that have been widely adopted since that time.
This sort of medical agnosticism has the advantage of incorporating a kind of intellectual modesty into its refusal to judge complex behavior. “We do not presume to know whether bias is truly at work in this setting,” two medical authors state in their 1999 article on “Racial Disparity in Rates of Surgery for Lung Cancer.” “Evidence that bias on the part of physicians (either overt prejudice or subconscious perceptions) influences access to optimal cancer care is disheartening,” they comment, but it is too soon to tell whether even “subconscious perceptions” might be affecting the therapeutic relationship.92 These authors, like Geiger, await “definitive” proof that would “truly” convince them. “Researchers,” the Chronicle of Higher Education reported a year later, “want to investigate further whether minority patients are intimidated by white doctors, or whether doctors use medical terminology that some undereducated people, whatever their race, may have particular difficulty understanding.”93
Even a passing familiarity with American social history would have assisted the researchers who were trying to figure out whether black patients might be intimidated by white doctors. Intimidation in every social venue was the social logic of Jim Crow racism, and the social universe of American medicine was no exception to this rule. The real question here is how medical researchers could be so unaware of the basic facts of life regarding race relations in the United States during the course of the twentieth century. This historical ignorance leads in turn to medical complacency toward the feelings of black patients whose personal histories lead back to the long era of Jim Crow medicine. Today's physicians seem to be unaware that the prejudices and practices of their predecessors traumatized generations of African Americans, for whom a distrust of white doctors became a cultural legacy that persists to this day on a scale few whites can imagine. Once again, the real mystery posed by these researchers is how they could have embraced the naïve assumption that black-white relations in medicine can be studied outside of the historical context that shaped them.
The agnostic approach to health disparities continues to predominate in the medical literature. The authors of a 2005 report on the management of heart disease in blacks and whites, which documents the persistence rather than the narrowing of racial health disparities, conclude the following: “Despite considerable debate, reasons for these differences are largely unknown. Potential explanations are sex and racial differences in eligibility for treatment, clinical contraindications, and confounding by other clinical factors.” These authors propose that “persistent differences in treatments and procedures according to sex and race reflect some unmeasured characteristic of patients or a health care factor that has not changed over time.”94 The racist phase of American cardiology and its diagnostic legacy that are examined in Chapter 3 go unmentioned and, I suspect, unimagined by these authors. What is more, every explanatory term they use is obfuscating, misleading, or essentially meaningless. “Eligibility for treatment” usually refers to poverty; “clinical contraindications” can result from judgments by physicians that may express racial bias; “unmeasured characteristics” can include various aspects of an African American identity that may complicate diagnosis and treatment; a “health care factor that has not changed over time” could be virtually anything, including medical forms of racial bias. As we will see in greater detail, those medical authors who address racial issues in the professional literature employ a terminology and a rhetorical strategy that effectively eliminate the relevant historical factors as well as accurate descriptions of how race relations work in the world of American medicine today.
One issue that most medical authors evade is whether physicians have a responsibility to monitor their own unconscious motivations for the purpose of earning and retaining the trust of their patients. David Levy's 1985 paper on doctor-patient relationships introduces the basic distinction about conscious and unconscious behaviors. “The white physician,” he points out, “need seldom contend with conscious prejudice in himself. However, he must be alert to the possibility of unconscious prejudice or negative counter-transference which impedes the doctor-patient relationship.” For example, “unconscious prejudice may cause the white physician to over-identify with the black patient, i.e., lean over backwards and become overindulgent, paternalistic, and condescending.”95 But Levy's emphasis on the doctor's responsibility to monitor and adjust for his own state of mind—a well-known professional obligation of the psychiatrist—has not been taken up by the medical commentators who followed him.
Knowledge of the racial dimension of our medical history would also curb the temptation to excuse racially biased behaviors by distinguishing between “overt” and “subtle” misbehaviors. The physician's obligation to practice a degree of self-observation is noted by a few of the physicians who have touched on the interpersonal dynamics of race relations in medicine. “Many physicians would deny,” John Z. Ayanian wrote in 1993, “that overt racism affects medical decisions, but few could overlook the subtle racial biases that can permeate reasoning and communication with patients and other physicians.”96 Here the distinction between overt and subtle is not invoked to excuse “subtle” physician behavior that might also be of “unconscious” origin. But the standard presentation of scenarios involving potential bias addresses the issues of motivation and self-awareness by establishing the racial innocence of the medical personnel whose behavior might be questioned. An early (1980) paper on measuring racial bias offers the following response to the discovery of possible bias: “Based on these measured treatment differences we conclude that there is some indication of racial bias. Our experience with the staff indicates that this bias is not due to hostility or contempt for black patients but from subtle stereotyping and greater familiarity with and preference for white patients. Feedback of the results of our data to the staff was met by an openness to consider racial bias as a possible explanation” [emphasis added].97 The medical staff is given a clean bill of emotional health vis-à-vis race on the basis of the authors' “experience” with them. The preferred explanation of possible bias is, as is so often the case in these publications, “subtle stereotyping” for which no one is directly responsible. The “preference for white patients” that might be a sign of racist feelings about blacks is left unexplored.
Emphasizing the distinction between open racial hostility (“overt racism” or “overt prejudice”) and ostensibly unconscious prejudice (“subtle racial biases” or “subconscious perceptions”) is an essential