Review - Race in Contemporary Medicine
by Sander L Gilman (Editor)
Routledge, 2008
Review by Robert L. Muhlnickel, MSW
Oct 21st 2008 (Volume 12, Issue 43)

Introduction

Sometimes it's an adventure to review a book about which one knows only the title. With Race in Contemporary Medicine this analytically trained philosopher entered the foreign land of 'race studies,' heavily influenced by the methods, assumptions, and modes of expression cultural studies. I chose to review the book, though I am not expert in its field, because the issues it raises are important not only to specialists in its field, but also to philosophers, ethicists, clinicians, and policy-makers.

Race in Contemporary Medicine began life as a special issue of Patterns of Prejudice, a journal devoted to social analysis of race, ethnicity, nation, and color. The authors expectably share methodological and substantive assumptions. Among these are that race is a social construction, that the concept of race was invented by European Enlightenment-era thinkers, and that race should not be used as a research classification in biology, genetics, and medicine. The essays respond to recent claims that there are legitimate conceptions of race based on genetic markers, decisions by educational and medical institutions to collect data based on racial classification, and the announcement of BiDil, the first drug approved by the Food and Drug Administration because of its supposed effectiveness among African-American patients and marketed specifically for a specific ethnic or racial group.

These essays are written with the full panoply of their academic specialty in cultural studies: numerous footnotes to academic, journalistic, and popular sources, use of obscure, hyphenated theoretical concepts, references to 'reading' 'textuality,' 'articulation' 'empowerment,' 'discourse' and 'production' without clarification or explanation, and combining statistical, literary, and aesthetic analysis. Non-specialists will not easily understand these essays.  Analytic philosophers of science and moral philosophers will find this unfamiliar territory.

          The authors take up several important questions:

1)   Is 'race' an apt biological classification?

2)   Is 'race' a mere concept, without independent basis in biological fact?

3)   Can 'race' be used in medical research without entailing 'racist' attitudes, behaviors, structures, or beliefs?

4)   If population genetics shows continuous variation among human populations rather than essential differences between 'races' should racial classification be used in medical research?

5)   What is the significance of non-scientific uses of racial assignment for scientific and medical research?

6)   How are the meanings of racial and ethnic concepts established in scientific and medical research?

7)   What is the significance of racial concepts for medical practice?

The answers to these questions are important for our understanding, that is, for acquiring justified beliefs about us, we humans, the object of inquiry that touches on each person individually and for us all collectively. They have implications for how we treat one another in medicine, politics, education, so they have implications for moral judgment in social justice and social policy. The issues addressed in these essays are not only important to attitudes toward African-Americans or blacks but also are important to attitudes to other groups. They arise in understanding Jewish and Asian groups' supposed genetically transmitted resistance to alcoholism, attempts to find Jewish ancestors among Spanish settlers in New Mexico, and efforts to trace genetic predisposition and resistance to disease among Han Chinese, Hawaiian, and Caribbean populations.  The aims of understanding and determining how best to treat one another should be of universal interest.

Appreciation

The authors' collectively impress me with the wealth of data, examples, and reasons they assemble to show the complexity of the process of racial assignment by humans. Anyone who thinks that simple essences or readily recognized biological natural kinds constitute the groups to which racial classifications are conventionally assigned should question that belief upon reading this work.  The essays by Azoulay, Neulander, Gilman, and Graves and Rose are especially useful in this regard.

Wald, Alcabes, Neulander, and Gilman discuss the relations between non-scientific race concepts and the concepts of 'race' and 'ethnicity' adopted for scientific research. Neulander discusses this phenomenon as a case of 'folk logic' informing 'academic logic,' though the issue is a matter of 'folk taxonomy' or classification, as in the essay's title. The essay discusses the sudden appearance of 'Jewish' symbols among ancestors of New Mexicans, which then were taken as evidence of 'whiteness,' despite clear evidence there were no Sephardic Jews among Spanish settlers of the area. A researcher later accepted this folk or non-scientific classification as a substantiated claim and it found its way into a historical work published by an academic press. Neulander also shows that the non-scientific classification confuses the religious classification Judaism with the racial classification Jewish and that the confusion reoccurs in the academic work cited. 

Several essays discuss Howard University's announcement that its medical research centers plan to collect data on racial classification of its patients with the goal of determining mortality and morbidity rates of diseases, the prevalence of disability, and overall health status among African-Americans. The goal appears to be to collect data typical of the 'black experience' so that medical services can be targeted to reduce health disparities between African-Americans and other U.S. citizens. Snyder and Mitchell point out problems making inferences from the sample from which the data is collected, since patients who obtain services at Howard's clinics are presumably poorer, less powerful, less educated, and already identified as suffering from disabilities (p. 98). Soo-Jin Lee identifies a contradiction, or at least a tension, in official descriptions of the project, which affirm that there is more similarity between the genomes of African-Americans and Caucasians than between the genomes of different Caucasians, and that the study of "African-American genes" is useful for fighting disease (pp. 152-3).  The problem is that 'race' is a highly ambiguous category, since it is a conventional classification found in pre-theoretical and non-scientific thinking, it is a classification based on statistical analysis of the human genome, it has been at times a sociological and anthropological classification, and it is a classification tied to racist ideologies and attitudes. If the authors are correct, these ambiguous uses are hard to detect in communications 'packaged' as science or based on science (as in Azoulay's analysis of a CSI episode and Wald's criticism of the narrative conventions indicating racist hierarchies in the PBS special 'Odyssey of Man), that scientific researchers are often unclear about which of the multiple concepts of 'race' they are using, and that adopting a classification that has been part of racist ideologies and attitudes risks importing racist concepts into research that is intended to guide medical policy and practice.

This leads me to another topic. There are many risks in adopting 'race' as a classification in scientific research. The ambiguity of the concept to which researchers, subjects, research funding sources, and practitioners refer by the term is the root of other possible risks. One important risk is that use of 'race' by members of research, medical, and social service bureaucracies leads them to conceive of race as a property they think is essential to the person subject to classification, intrinsic to the person who is so classified, and based on beliefs that membership in the class denominated by the property is permanent or eternal or unchangeable. The authors support an alternative, for members of research, medical, and social service bureaucracies to use 'race' as a product of racism or racially discriminatory attitudes so that the problems, conditions, and diagnoses of those who are members of particular races are understood as the result of racism and racial discrimination to which they are subject. No author in this anthology to my knowledge considers sufficiently the possibility that members of those bureaucracies can use 'race' as a reasonable classification and that racism has harmful effects on those who are so classified. The point that racist policies, practices, and attitudes harm those who are subject to them and that those harms influence the presentation of those persons in research, medicine, and social service is well-taken. I agree that in some circumstances racial classification and racism are mutually supporting attitudes. I am less sure than the authors of what the connections between the harms of racism and the use of race classification are and less sure than they that the connections cannot be severed. 

Some things to think about

In Part Two of Wald's essay we get extensive criticism of the film Odyssey of Man, and the way its cinematic conventions supposedly "reproduce racism." The metaphor or concept of reproduction is difficult for me to understand here. I do not find it illuminating to think of a film as the descendant of a general moral term. I think what is meant is that the film's message is best explained as motivated by racist attitudes or conveys racist beliefs, although those attitudes or beliefs are not conscious.

The film criticism is followed by the claim that scientific explanation is one story among others--without mentioning that some propositions organized in certain relations might be better explanatory theses than others–as if resorting to the language of  "story" and "myth" makes scientific explanation parallel with and equally valuable with creation myths. If Wald's point is that creation narratives have a value that scientific explanation lacks and that scientific explanation has a value that creation narratives lack, this is a banal but true point.  It can be re-stated as scientific explanation and creation narratives have different values. More likely, the point is that scientific explanation sometimes 'functions' as creation narrative. If scientific explanation has same function for some linguistic and cultural group as non-scientific creation myths do for other linguistic and cultural groups, this is a point on which I would welcome evidence and reflection. It might be that the scientific explanation does not function well as creation narrative, and we might ask why. If non-scientific creation myths and scientific explanation serve the same function, then they can by judged by the same standards. But that would require considering questions about truth of cosmological claims, which Wald never mentions. If non-scientific creation myths and scientific explanation serve different functions, thereby requiring judgment by different values, then the point of the comparison is lost.

It is a commonplace of certain sorts of social analysis of scientific work to compare scientific explanation to non-scientific narratives and myths. The point of such comparison needs more careful statement and evaluation before its point is clear to me.

Elsewhere we get what seem to be versions of a similar claim about the usefulness or value of 'race' as a category in scientific research. One contributor urges "to consider the implications of thinking through the prism of 'difference' and 'race' in biomedical and genetic research while bearing in mind the following principle: the concept of 'race' cannot be sanitized, salvaged, or made palatable" (p. 50). The best understanding I can propose for the obviousness of a proposition P is that the denial of the original proposition, that is, ~P, is undeniably false. The claim that the absence of human races should be obvious is then an epistemic claim, a claim concerning what is reasonably believed about the proposition concerning the absence of human races.

Elsewhere we are told, "the absence of human races should be obvious" (p. 180). Like the first, this is best understood as a modal claim:

Q: the concept of 'race' cannot be sanitized, salvaged, or made palatable.

That some modal force is meant for the claim that race cannot be sanitized, salvaged, or made palatable is indicated by cannot. However, it is not clear what sort of modal claim is intended. Q is a claim about a concept humans have and use. Is the modal force logical impossibility? An a priori claim? These are patently false. Is Q an inductive claim so firmly established that only the best evidence one could acquire can override it? The essays in this collection respond to other thinkers who think they have evidence that makes ~Q plausible. Do the authors of these essays think the others are deluded, misguided, or expressing racism without being racist? The last would make Q a moral claim, stating that we humans cannot use 'race' as a descriptive concept without doing something morally bad.

The authors' passion for their subject is apparent and the subject is important. It is disappointing that the essays is this collection do not attend to the use of the concepts and terms associated with epistemic and metaphysical claims and to the logical status of their own claims. They do not engage fully with those who disagree with them. Philosophers as diverse as John Arthur, Hans Jonas, and Peter Singer have affirmed that the concept of 'race,' captures some important factual claim and that the truth captured by the concept is assertible at the same time one opposes racism. I have not been persuaded otherwise by this collection.

© 2008 Robert L. Muhlnickel

Robert L. Muhlnickel, MSW, has been a clinician and teacher in the University of Rochester Department of Psychiatry and is completing his Ph.D. dissertation in Philosophy at the University of Rochester. He also works on a grant training clinicians in evidence-based family practices for people with serious and persistent mental illness, co-sponsored by the NYS Office of Mental Health and University of Rochester Medical Center.