Author: Savannah de Groot
Hippocrates, an ancient greek physician, devised an ethical code for physicians and future physicians to uphold within medical practice, the Hippocratic Oath. This oath, widely recited by successfully graduated physicians and by other medical professions today, initially marked the departure of understanding medicine as a magical and/or religious observation, focusing primarily in class-based cures to an inner calling to provide service for the sick. Today, translated and interpreted, the Hippocratic Oath serves as a lasting model for professional conduct and integrity in the practice of medicine. After the grueling eight-some years of post-secondary education, orally repeating and effectively taking an oath seems easy enough, right? If this is true, how may we explain health disparities based in race, ethnicity, and gender? To answer this question, it may be of use to focus on two particular passages from the Hippocratic Oath.
The first passage, a translation from Greek by Ludwig Edelstein, the Hippocratic Oath reads, “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice” (Edelstein, 1943). Although this passage precedes the American civil rights movement, women’s liberation movements, and other grandiose social movements, it nonetheless states an ethical obligation to provide accessible health care to the sick free of injustices (i.e. racism, sexual harassment, inappropriate patient-doctor relationships etc.)
Today, a modern version of the Hippocratic Oath, translated and interpreted by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University is most commonly used in medical schools. The second passage reads, “I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism” (Lasagna, 1964). This passage indicates an ethical obligation to be selfless in the care required for patients - doing everything possible to uphold a balance between overtreatment and negligence.
I’d like to take the opportunity to clarify what I perceive as the definition of race and the popular discourse surrounding it at this time, especially in discussing its impact on health disparities, or medical racism. From personal observation, there appears to be two dominant racial ideologies. The first is an understanding of race as a static characteristic, this suggests that the differential treatment of individuals in society is based in biology. Within this ideology, one may hierarchically organize humans based on perceived biological inferiority or superiority. Widely welcomed today, a prevalent understanding of race is that it is a social construct, this suggests that race is dynamic, operating differently in varying times and spaces. Within this ideology, one may be considered black in the United States, and considered white in another country. An example illustrating race as a social construct is the Cheddar Man, a 10,000 year-old mesolithic skeleton which demonstrates that white or light skin characteristics of modern Europeans is a relatively recent phenomenon. Progressive? Yes. Prone to the logical fallacy of post hoc ergo propter hoc? Yes.
A troublingly prevalent reaction to understanding race as a social construction is committing the logical fallacy of post hoc ergo propter hoc, or a post hoc fallacy, in which one draws a sweeping conclusion based on a single event. This produces a discourse of contemplating why race matters anyway and subsequently the concept of ‘colourblindness’. While race may be socially constructed, it nevertheless has real and ubiquitous effects on the individuals racialized.
Within medicine, similarly to sex and age, race is viewed statically and/or as a biological marker which would suggest that racial differences are based in genetic variation. However, it has been shown that genes linked to skin colour or race have no ability to determine diseases, especially considering our friend, the Cheddar Man. This is very problematic because a static understanding of race within medicine becomes the determining factor in the health care received or lack thereof.
For example, take the racialization of sickle cell disease where a causational relationship between sickle cell disease and race have been drawn to subsequently argue that race is a risk factor in acquiring the disease. In reality, sickle cell disease is prevalent in those of Middle Eastern, Indian, Mediterranean and African descent because those geographic regions have high cases of malaria, “the gene variant for sickle cell disease is related to malaria, not skin color” (American Anthropological Association, 2016). In this example, the twin traps of medicine Hippocrates previously alluded to, walk a thin line between overtreatment and negligence. The racialization of disease leaves open the possibility for a medical professional to rule out viable prognoses, a decision informed by racial ideologies. This action fails to uphold the Hippocratic Oath.
Similarly, Serena Williams spoke about the complicated experience she underwent while delivering her first child, she writes, “I am so grateful I had access to such an incredible medical team of doctors and nurses at a hospital with state-of-the-art equipment… If it weren’t for their professional care, I wouldn’t be here today” (Williams, 2018). She continues in her personal piece for CNN, “...black women in the United States are over three times more likely to die from pregnancy or childbirth-related causes” (ibid). Unlike Serena’s relatively fortunate case, many women of colour do not have the same experience upon hospital admittance. Consider a study of racial biases in pain assessment and treatment conducted by Hoffman et al., which asked medical students of the University of Virginia to assess two imitation medical records from a black and a white patient. They were asked to estimate the pain and suggest a treatment. The results of this study concluded that medical students who endorsed a racialized understanding of pain and disease (i.e. “black people’s nerve-endings are less sensitive than white people’s nerve-endings”) rated the black patient participant as feeling less pain than the white patient participant (Hoffman et al. 2016).
It becomes overwhelmingly necessary at this point to suggest an intersectional lens of analysis for the experience of pregnant/new black mothers in medicine. Women of colour experiencing pregnancy or childbirth, like Serena Williams, exemplify how race and gender are not mutually exclusive within the sphere of medicine. Gender and race are socially constructed categories - identities not rooted in biology but social context - this suggests that women of colour have two social oppressions operating or overlapping. In this case, women of colour experience racial and gender-charged stereotypes of masculinity or toughness and within the sphere of health care, this is the determining factor in whether or not an individual will receive care, and if so, how much care they will receive. Employing an intersectional lens illustrates how women of colour experiencing pregnancy and/or childbirth are not experiencing healthcare of ethical standard. Is the Hippocratic Oath, then, a waste a breath? Where do we go from here? Is it a course for all undergraduate students and graduate students on the basic know-how’s of race, gender and other social identities? Is a major revision to the medical ethical code of practice necessary? Is the oral repetition of an oath swearing to never view social categories as biologically-rooted the answer?
I think that medical racism, specifically how women of colour experience medicine, is a strong example of how, yes, race is a social construct but that this sudden understanding is not the end-all to racial and gender oppression - there are real effects to this understanding. Concepts of racial ‘colourblindness’ are problematic, if not worse, as the concept tends to silence these real and varying experiences.
Finally, I have a suggestion. Let us kill two birds with one stone; let us acknowledge race as a social construct with real effects and let’s just listen - don’t say anything - just listen.