A medical professional in surgical clothing holds hands with a patient. Photo by Kaboompics.com via Pexels.
Hermon Welde is a public health science major and she is a 2024-25 health care ethics intern at the Markkula Center for Applied Ethics at Santa Clara University. Views are her own.
There is no genetic marker for race. The completion of the Human Genome Project in 2003 upheld the fact that humans are 99.9% identical at the genetic level, and DNA cannot determine whether someone is white, Black, Asian, Latine, etc. Despite this scientific clarity, racial misconceptions have led to a longstanding period of misguidance and misinformation on how health varies by race. Specifically within the Black population, health status has been marred by dangerous misconceptions regarding things such as pain tolerance, skin thickness, and susceptibility to drug addiction.
Regardless of evidence demonstrating race as not genetic, the concept of racialized medicine continues to block African Americans from receiving equitable care. Through a history of exploitative and presumptive practices, race-based medicine continues to foster an environment of mistrust and exclusion within the health care system. This perpetuates harmful stereotypes against people of color, leading to poor health outcomes and significant barriers to equitable access. This can be addressed by eliminating race-based medicine and adopting more inclusionary practices.
A History of Medical Exploitation of Black Americans
Among the brutal, discriminatory treatment enslaved people faced, medical exploitation was the most profound and detrimental. Black individuals were used as test subjects, fueling advancements through unethical experimentation. “Dr. J Marion Sims developed new surgical techniques through medical experiments on enslaved women… Dr. Francois Marie Prevost honed his cesarean surgical procedure by practicing on at least 30 enslaved women in Haiti and Louisiana during the 1830s. Dr. Ephraim McDowell, considered the father of abdominal surgery, developed surgical treatments for ovarian cancer in the early 1800s, often on enslaved women. The experimental procedures were often conducted without anesthesia due to the inaccurate belief that Black people felt less pain than white people,” writes KFF formerly known as the Kaiser Family Foundation in an article on the historical implications of racial health disparities.
These are just a few examples of the doctors and scientists who profited from the systematic dehumanization of Black individuals at the time. The procedures were not consensual and disregarded the cries of pain that came from the patients. These practices were rooted in beliefs developed in the mid 1700s–that Black people could tolerate pain significantly more than white people. Many doctors and scientists published material that cemented these inaccurate and dangerous beliefs, creating a new precedent of health misinformation. One example was the publication of The Natural History of the Human Species in 1842 by Charles Hamilton Smith, which continues to influence science and medicine in the modern era.
In this book, Smith creates a racial hierarchy, reinforcing these inaccurate beliefs about Black people and their health. It is also important to understand that these beliefs were largely created to justify slavery and support discriminatory hierarchies. If these individuals could “pinpoint” these so-called differences between Black and white individuals, it would allow for the continuation of these practices in which white, European superiority was being asserted.
The Tuskegee Syphilis Study: A Breach of Trust
The exploitation of Black people in medical research did not end with slavery but continued on well into the 20th century. These racial biases continued to shape medical decision making, most notably and one of the most unethical examples being the Tuskegee Syphilis Study. During this experiment, 600 Black men were used to study the “natural history and progression” of untreated syphilis. These men did not give informed consent and were not only deceived regarding their condition but also denied life-saving treatment. The Tuskegee Syphilis Study embodied the medical and scientific community’s dehumanization of Black people, reinforcing the systematic neglect and exploitation that persists in health care today.
Ethical Violations and Therapeutic Misconception
Here, we can see the violation of key ethical principles, most importantly informed consent and autonomy. By intentionally misleading and withholding vital information, researchers were able to manipulate participants. Researchers also exploited the socioeconomic climate, pressuring them into participating. Due to financial constraints, many agreed to collaborate for the sake of receiving medical “care.” This prevented them from fully exercising their autonomy and making informed decisions. As a result, a parallel can be drawn with the current ethical challenge of therapeutic misconception, a concept used to explain the instance in which participants of clinical trials can assume that the primary purpose of research is to treat them (Henderson et al., 2007).
This misconception poses a significant threat to informed consent, as it can prevent participants from fully understanding the nature of their involvement in a study. The Tuskegee Syphilis Study is often used as an example of unethical research, but since the participants were not told they were in a study, this scandal goes way beyond the ethical challenge of therapeutic misconception. While the degree of deception that took place during the Tuskegee Syphilis Study will probably never happen again in the United States, we must recognize that the issue of therapeutic misconception is still a major problem with serious implications.
Understanding Race-Based Medicine and its Effects
Understanding this historical context is crucial in recognizing where mistrust stems from and how racialized beliefs were developed. At the foundational level, when these theories of health were being developed, race was extremely influential. Subsequent medical research and discovery were based on these ideas. Today, race-based medicine continues to be responsible for the mistreatment of Black patients in a clinical setting. It is the combination of these factors that has pushed Black Americans to not trust the health care system and lose confidence, as it has been clear time and time again that intentions have been flawed from the start.
“We often assume that differences in disease incidence or outcomes between racial groups boil down to inherent biological groups, which is scientifically untrue–and often harms people of color,” says a doctor on a UCSF panel discussing racialized medicine.
Race-based medicine is defined as “a system that treats race as a biological variable and, when translated into clinical practice, leads to racial health inequities” according to the director of Health Outcomes at the Veterans Health Administration Office of Health Equity. Race-based medicine is seen in almost every aspect of health care. An individual’s skin tone should not be the reason why they are ignored, misdiagnosed, and mistreated.
Modern Manifestations: eGFR and Diagnostic Disparities
According to the Center for American Progress, Black Americans have some of the highest rates of chronic illness. “African Americans have higher rates of diabetes, hypertension, and heart disease than other groups… African Americans experience higher incidence and mortality rates from many cancers that are amenable to early diagnosis and treatments,” stated the report on health disparities by race and ethnicity.
Poor health outcomes can be traced to a multitude of things, including the environment one lives in. However, it should not be traced to false beliefs and misconceptions created during a time when being Black meant you were property and not a human. These beliefs manifest in issues like maternal mortality, lack of organ donations, lack of proper care, and so much more.
A recent example of race-based medicine is the race adjustment that is present in the estimated glomerular rate (eGFR) calculation that is used to determine kidney function. This calculation had included race to account for differences in creatine levels according to the American Kidney Fund. However, it became apparent that this adjustment was leading to overestimation of kidney function in Black patients. This overestimation leads to misdiagnoses and delays in receiving care, which also correlates with the statistic that Black people are four times as likely to develop kidney failure, but less likely to receive a kidney transplant.
Social Determinants of Health
Modern medical practices continue to reinforce racial disparities in health care. To improve health outcomes and create an equitable health system, re-evaluation and improvements must be made. By eliminating race-based medicine and prioritizing the environmental factors that influence health, we can reduce disparities and improve health outcomes. Social determinants of health provide insight into the factors that contribute to health disparities and can be used as a method to reform health care.
Increasing Inclusion in Clinical Trials
This issue can be addressed by increasing diversity in clinical trials, particularly among Black patients, to ensure their needs are addressed. This transition can be understood through Kant’s ethical framework, which warns against treating individuals as a means to an end. Historically, Black people were once exploited for medical research, and now they are not included in critical clinical trials and research. According to data collected by the FDA and NIH, “Among 32,000 individuals who participated in new drug trials in the U.S. in 2020, only 8% were Black.” Minority groups continue to bear a disproportionately high burden of chronic illnesses despite low rates of participation. Including underserved populations, particularly Black populations, is essential to rebuilding trust and ensuring that scientific research remains valid and ethical.
Conclusion: Rebuilding Trust Through Truth and Equity
The legacy of bias in medicine continues to shape health care, reinforcing disparities and mistrust among Black patients. As a result of a tumultuous history full of unethical experimentation and exclusionary practices, the health system has failed people of color. These misconceptions have persisted for centuries, and if left unacknowledged, they will continue to harm millions of Black individuals in the United States. A shift in perspective is needed to address the inequities and disparities that continue to persist. Given the long history of medical experimentation and exploitation, shifting toward ethical and inclusionary medical research will allow for the trust to build. Medicine has the power to do great things, but only if centered on truth, equity, and inclusion. Racial biases should not be the deciding factor between one’s life or death.