STUDENT VOICES | THE 2024 CHYNN ETHICS PAPER PRIZE second place WINNER

By: Deborah Adebanjo, FCLC ’26

This year, my mother started complaining about getting constant migraines, and eventually, she went to her doctor to figure out why. The doctor said there was nothing wrong and that it was probably just stress and prescribed her pain medication. However, the pain kept persisting. My family and I knew something was wrong, so we urged the doctor to do an MRI. It turned out that my mum had a brain tumor, and right now, she is in treatment. It was a very close call. I am sure things could have quickly turned fatal if my family and I had not urged the doctor to do an MRI. Why am I bringing this up, you might ask? Well, I feel that this situation that I faced with my mum is one of many stories of Black women who face medical diagnostic testing delays because of not being believed by doctors when they expressed pain or discomfort and showed symptoms of needing testing. In my experience, this has to do with doctors not seeing the humanity in Black women.

The ongoing moral and ethical issue of Black women facing a delay in medical diagnostic testing is extensive. This issue is persistent because doctors have implicit biases that prevent them from seeing the humanity of Black women. There is an unjust distribution of healthcare resources and services and systemic discrimination within the healthcare system. Research shows that 50.9% of Black patients (as opposed to 60% of white patients) received MRI testing for cognitive impairment (RNSA 2023). These findings indicate that obtaining MRI imaging was notably less frequent among Black patients. Subsequent studies have shown that Black women exhibit notably reduced likelihood of undergoing screening mammography in comparison to White women, and this is because of an absence of recommendations from physicians (Ahmed et al. 2016; O’Malley et.al. 1997). It is evident from these findings that there are delays for Black women in receiving disganostic tests compared to their White counterparts.

It is also clear that these delays are partly due to doctors not recommending screenings promptly. These delays are due to the implicit biases that doctors have about Black women. Research shows that implicit bias is just as widespread among healthcare professionals as it is among the general population (Bridges 2015). Thus, physicians, like the general population, exhibit implicit biases when it comes to race, and more specifically Black people. This trickles down to Black women. These biases can impact the way healthcare is provided and contribute to the health disparities that Black women like my mother deal with.

To understand these disparities, let us consider the underlying theoretical and ethical issues. In particular, Charles Mills’ idea of the “racial contract” and Margaret Urban Walker’s feminist critique of traditional models of ethics lay a foundation for considering implicit bias against Black women. Mills’ idea of the racial contract subverts the traditional social contract proposed by Enlightenment thinkers such as Thomas Hobbes. The racial contract establishes certain peoples as whites and full persons, whereas it categorizes all others as “nonwhite” and “subpersons.” This arrangement ensures the differential privileging of whites at the expense of nonwhites (Mills 1997, 11). Firstly, Mills’ theory of how the racial contract, “is not a contract between ( “we the people” ), but between just the people who count, the people who really are people (“we the white people”).”(Mills 1997, 3). This theory highlights the exclusivity of the racial contract, asserting that it is not a pact that encompasses everyone but is instead limited to a particular racial group, specifically White people. It depicts the unequal distribution of power and privileges based on race within a society’s social and political structures. Mills further expands on this idea:

[Non-whites] are designated as born unfree and unequal. A partitioned social ontology is therefore created, a universe divided between persons and racial subpersons… And these subpersons…are biologically destined never to penetrate the normative rights ceiling established for them below white persons. Henceforth, then, whether openly admitted or not, it is taken for granted that the grand ethical theories propounded in the development of Western moral and political thought are of restricted scope, explicitly or implicitly intended by their proponents to be restricted to persons, whites. (Mills 1997, 16)

Here, Mills describes a historical and philosophical framework that has relegated non-Whites to a lower moral and social status. He highlights how certain moral and political thought has justified and perpetuated racial hierarchy and discrimination. Due to the clear division between White personhood and non-White “sub-personhood”, Mills states that, “it is possible to get away with doing things to subpersons that one could not do to persons, because they do not have the same rights as persons”(Mills 1997, 56). Thus, the racial contract makes it possible for “subpersons”, such as non-White people, to be discriminated against. The racial contract also allows for doctors to discriminate against Black women.

From a feminist prespective, Walker describes traditional ethical models similarly. These ethical models tend to have uniform expectations concerning moral judgments, without taking into account particular circumstances (Walker 2007, 77-78). For example, my mother’s specific concerns and symptoms were not taken seriously because the medical field does not consider race-specific issues. Like Walker’s model, the medical institutions emphasize a closed community where everyone makes similar judgments based on uniform generalizations. This type of model, both in ethics and in medicine, contributes to healthcare disparities that Black women face with doctors. It may contribute to Black women not being heard or fully understood by doctors, as their experiences may differ from established norms or expectations within the healthcare system.

Scientific research and philosophical perspectives confirm that there is an implicit racial bias that doctors have against Black women. It ultimately is a detriment that affects Black women in having a delay in diagnostic testing. It is in part due to how society has set up women of color such as Black women to be mistreated, unheard, and disregarded through channels such as the racial contract and traditional ethical models.

Possible objections to the issue that I bring up with doctors not prioritizing Black women in the healthcare field is that aiming to prioritize Black women with overly prescriptive policies to address disparities could interfere with the autonomy of medical professionals. For example, Philosopher Stephen McAndrew argues: “Society…requires medical professionals to autonomously govern themselves by rules that are generated by the use of their expertise. Society grants this autonomy because doing so provides greater benefit than harm to society.” (McAndrew 2019, 201). For McAndrews the patient’s perspective does not matter (McAndrew 2019, 203). McAndrew argues that it is essential to trust and allow medical professionals to exercise their expertise and professional judgment in the best interest of patients and society. These objections do not negate the ethical concerns surrounding racial disparities in healthcare. While professional judgment is crucial, addressing biases within the healthcare system is essential. Additionally, addressing and acknowledging these issues by starting with the perspectives and experiences of Black women, who are most affected, can lead to the broader aim of having health care equity.

How can this issue be addressed in practice and through the philosophical and ethical lens? Implementing anti-bias training, promoting diversity in healthcare professions, and creating policies that guide professional judgment without compromising patient care can help ensure fair treatment for all individuals, especially Black women. Addressing the implicit biases would significantly reduce the delays that Black women face in getting diagnostic testing. This is supported by findings from a study that showed how after participating in an implicit bias awareness education course, academic health care providers who teach showed a notable increase in their awareness of bias. This shift was primarily influenced by a heightened understanding of societal inequities (Sabin et al. 2022). Efforts such as anti-bias training and policy reforms hold promise in mitigating delays in diagnostic testing for Black women.

Additionally, Walker’s contemporary feminist model of ethics is much more effective in addressing this problem because it emphasizes amplifying marginalized voices, like the voices of Black women regarding the medical care they receive. Since her model, “ looks at moral life as a continuing negotiation among people, a practice of mutually allotting, assuming, or deflecting responsibilities of important kinds, and understanding the implications of doing so.”(Walker 2007, 67), and is also “ designed to capture interpersonal and social features of morality.” (Walker 2007, 67). Applying her model to healthcare interactions can help amplify Black women’s voices by fostering collaborative decision-making, understanding the implications of healthcare choices, and valuing diverse experiences. This approach promotes a more inclusive and patient-centered healthcare system that will help support Black women.

Unless this issue is urgently addressed, the same thing that happened to my mum and worse will surely continue to happen to other Black women.

References

Ahmed, Ahmed T., et al. “Racial Disparities in Screening Mammography in the United States: A

Systematic Review and Meta-Analysis.” Journal of the American College of Radiology: JACR, vol. 14, no. 2, 1 Feb. 2017, pp. 157-165.e9, http://www.ncbi.nlm.nih.gov/pubmed/27993485,

America (RSNA), Radiological Society of North. “Black Patients Face Delays in Alzheimer’s Diagnosis.” Www.prnewswire.com, 27 Nov. 2023, http://www.prnewswire.com/news-releases/black-patients-face-delays-in-alzheimers-diagnosis- 301997400.html. Accessed 15 Dec. 2023.

Bridges, Khiara. “Implicit Bias and Racial Disparities in Health Care.” American Bar Association, 2015,

http://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the-state-

of-healthcare-in-the-united-states/racial-disparities-in-health-care/.
McAndrew, Stephen. “Internal Morality of Medicine and Physician Autonomy.” Journal of

Medical Ethics, vol. 45, no. 3, 2019, pp. 198–203. JSTOR,

https://www.jstor.org/stable/26884784. Accessed 15 Dec. 2023.
Mills, Charles W. The Racial Contract. Cornell University Press, 1997.
O’Malley, M S, et al. “Race and Mammography Use in Two North Carolina Counties.”

American Journal of Public Health, vol. 87, no. 5, 1 May 1997, pp. 782–786,

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1381050/. Accessed 15 Mar. 2024.
Sabin, Janice, et al. “Brief Online Implicit Bias Education Increases Bias Awareness among

Clinical Teaching Faculty.” Medical Education Online, vol. 27, no. 1, 17 Jan. 2022, p.

2025307, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8765255/,

https://doi.org/10.1080/10872981.2021.2025307.
Walker, Margaret Urban. Moral Understandings. Oxford University Press, 2007.