Martin Luther King Jr.'s 1966 quote, that “Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death,” remains sadly relevant today (Galarneau, 2018). Historic racial injustices persist in many forms within the modern United States healthcare system, and disparities in treatment and outcome are only one example. Even within individual hospitals, after accounting for the fact that racial minorities often receive care at worse hospitals, racial disparities remain. Reconstructing the prominent debate between Tommie Shelby and Elizabeth Anderson within the healthcare context, I argue that black patients who request for black clinicians are legitimately practicing self-segregation 1.
The US healthcare system exhibits many forms of racial injustices that motivate patient requests for clinicians of a specific race. However, because broader societal disparities, such as the social determinants of health, require government responses that exceed the scope of individual institutions, I argue that institutional hospital policies should primarily consider—and minimize—the racial disparities within their own patient population. Regardless of the exact causal responsibility of these disparities and the blameworthiness of hospitals, hospitals should minimize racial disparities, without exacting additional burdens on patients, by acceding to certain race requests.
To justify this institutional response, I will apply Tommie Shelby’s (2014) argument for residential self-segregation to the field of medicine. However, a full appreciation of his argument requires more context. More specifically, Shelby writes in response to the “new integrationists,” who believe that integration is a necessary and uniquely powerful means for realizing social justice. Elizabeth Anderson (2010), for example, argues that residential integration can right the harm of social segregation by race. While the large-scale integration that she envisions is a matter for governments and not hospitals, her support for integration is worth highlighting here. For Anderson, integration encourages interracial cooperation and communication, which are necessary for overcoming incompetence in interracial interactions and unconscious negative stereotypes (110-113). Since implicit affective and cognitive biases cause unjust discrimination (65), reversing these biases through integration can go a long way in remedying racial injustice.
Given these benefits of integration, Anderson’s argument can be used to deny all race requests within a hospital. A survey by Hoffman et al. (2016) found a substantial number of white medical students and residents who believe in false racial biological differences, and other studies have demonstrated how these implicit beliefs and affective biases could account for differential treatment and outcomes. For Anderson, integration is therefore necessary for remedying unconscious prejudices and minimizing racial disparities. If black patients are allowed to self-segregate and are exclusively treated by black clinicians, hospitals would be “depriv[ing] nonblack [individuals] of the experiences they need to overcome anti-black racial bias” (183). Instead of approving race requests, it seems that Anderson would favor policies that ultimately lead to successful interracial patient-physician relationships: correcting racial biases by white clinicians, monitoring patient records to detect disparities, and supporting black patients who report mistreatment. Rather than allowing patients to choose the race of their clinician, it is more important to equalize the treatment of white and black patients and eliminate implicit biases within the white-dominated field of medicine. And given the current state of medicine, with a dearth of black physicians, and where black patients even within the same hospital may not have access to the same services, Anderson’s proposal does have its appeal.
Responding to Anderson and other “new integrationists,” Shelby (2014) makes a strong case for self-segregation as a protective act for disadvantaged groups (271). As Anderson herself concedes, integration can generate greater racial conflict before realizing its promised benefits. Consequently, Shelby claims that black Americans, who are already disadvantaged, should not be expected to bear the sacrifices of integration (281). Even if integration delivers better outcomes, black Americans are not wrong to self-segregate. The right for disadvantaged groups to protect themselves outweighs the imperative to integrate, and nonblack individuals are not being deprived of interracial experiences because they are not entitled to these possibly harmful experiences in the first place.
Although Shelby disagrees with Anderson’s imperative to integrate, his theory also promises to remedy racial disparities within hospitals. For Shelby, precisely because black patients are vulnerable to implicit biases and structural injustices, they must be allowed to protect themselves by self-segregating and requesting for a black clinician. This position is reinforced by empirical research showing that patients treated by a clinician of the same race have better experiences, possibly due to better communication and decreased bias between patient and physician (Takeshita et al., 2020). Therefore, for a hospital with racial disparities in patient outcomes, self-segregation provides a reliable way for remedying racial disparities, which then justifies requests by black patients for black clinicians.
So far, I have applied Anderson and Shelby’s respective arguments to the question of race requests, with the conclusion that both integration and self-segregation can remedy inequalities. However, this comparison does not take into account the medical setting, which introduces additional considerations and favors Shelby’s argument. Unlike cases of residential and social integration, where the original debate occurred, medicine does not involve citizens on equal standing. Instead, physicians owe patients a duty of care that goes beyond our common duty to each other. This duty obligates the clinician to consider the patient’s best interests and, more importantly, to do no harm. Therefore, the request for patients to “play [a] role in the moral reform of [white clinicians]” (Shelby 282), or, in Anderson’s words, to provide “the experiences [needed] to overcome anti-black racial bias” (183), is significantly more demanding. Even if the typical citizen may have a claim to these experiences, a physician or hospital must not expect this from their patient, especially when interracial contacts can initially cause harm. As such, the right to self-segregation and self-protection in medicine far outweighs the imperative to integrate, and hospitals must allow for race requests by black patients.
Importantly, within-hospital disparities are necessary for justifying race requests, because self-segregation is justified by its protective effects. Admittedly, this condition is complicated by the fact that mis-perceived mistreatment can equally harm the actual patient experience and quality of care. Here, the hospital will have to determine whether patient concerns are legitimate—for example, a white patient who rejects a black clinician may simply be racist, and a black patient may still be concerned about hospitals with perfect records. This determination of motives explains the difficulty of constructing a uniform hospital policy towards patient requests, as patients can sincerely hold unjustified beliefs and be influenced by them. However, this is also where the Shelby-Anderson debate becomes helpful. Although Shelby’s argument is better suited for the medical setting, there will be cases where patients have a weaker claim to self-protection. It is even possible that a patient, due to their past experiences, has a legitimate claim to self-segregate, although the hospital, given its perfect record, is justified in practicing integration. By borrowing the lens of integration and self-segregation, rather than providing a straightforward answer, we can much better appreciate these conflicting considerations and construct a nuanced institutional response that is sensitive to a patient’s motivations and medical needs.
References
- Anderson, E. (2010). The Imperative of Integration. Princeton University Press.
- Galarneau. (2018). Getting King's Words Right. Journal of Health Care for the Poor and Underserved, 29(1), 5–8. https://doi.org/10.1353/hpu.2018.0001
- Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. PNAS, 113(16), 4296–4301. https://doi.org/10.1073/pnas.1516047113
- Shelby, T. (2014). Integration, Inequality, and Imperatives of Justice: A Review Essay. Philosophy & Public Affairs, 42(3), 253–285. https://doi.org/10.1111/papa.12034
- Takeshita, J., Wang, S., Loren, A. W., Mitra, N., Shults, J., Shin, D. B., & Sawinski, D. L. (2020). Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open, 3(11), e2024583–e2024583. https://doi.org/10.1001/jamanetworkopen.2020.24583