Achieving Racial Harmony for the Benefit of Patients and Communities: Title and subTitle BreakContrition, Reconciliation, and Collaboration

Physicians have long been members of a special moral community. They have sworn to uphold ethical principles that, in the case of the Hippocratic oath, date back to the fourth century BC.

Several proclamations that undergird the medical profession speak to the primacy of equality. The “Prayer of Maimonides,”^{1 - 2} which first appeared in print in 1783 and is recited by many new medical graduates,³ asks God to preserve the strength of the physician's body and soul so that “they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being.”¹

The first Code of Medical Ethics of the American Medical Association (AMA), adopted in 1847 (the year the AMA was founded), was introduced with a statement on equity, noting that physicians use “zealous and methodical efforts for the relief of the suffering and unfortunate, irrespective of rank or fortune, or of fortuitous elevation of any kind.”⁴

The World Medical Association's Declaration of Geneva stated, in its original form adopted in 1948, “I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient.” The current version (last revised in 2006) expands that list of characteristics to include age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, and social standing.⁵ The Declaration of Geneva, in various forms, is also used by many medical schools as an oath for graduating medical students.³

These long-standing doctrines proscribe physician discrimination against patients based on sociodemographic characteristics and other traits. But a broader interpretation of these principles would compel physicians to treat each other, as well as their patients, without prejudice. In this regard the AMA failed, across the span of a century, to live up to the high standards that define the noble profession of medicine.

In an article published in this issue of JAMA, Baker and colleagues⁶ review and analyze “the historical roots of the black-white divide in US medicine.” This panel of experts, convened and supported by the AMA, found that (1) in the early years following the Civil War, the AMA declined to embrace a policy of nondiscrimination and excluded an integrated local medical society through selective enforcement of membership standards; (2) from the 1870s through the late 1960s, the AMA failed to take action against AMA-affiliated state and local medical associations that openly practiced racial exclusion in their memberships—practices that functionally excluded most African American physicians from membership in the AMA; (3) in the early decades of the 20th century, the AMA listed African American physicians as “colored” in its national physician directory and was slow to remove the designation in response to protests from the National Medical Association (NMA); and (4) the AMA was silent in debates over the Civil Rights Act of 1964 and put off repeated NMA requests to support efforts to amend the Hill-Burton Act's “separate but equal” provision, which allowed construction of segregated hospital facilities with federal funds.

These dishonorable acts of omission and commission reflected the social mores and racial segregation that existed during those times throughout much of the United States. But that context does not excuse them. The medical profession, which is based on a boundless respect for human life, had an obligation to lead society away from disrespect of so many lives. The AMA failed to do so and has apologized for that failure.⁷

In offering an apology, the AMA recognizes that contrition cannot remove the stain left by a legacy of discrimination. Instead, as Tavuchis⁸ notes, an apology “speaks to an act that cannot be undone but that cannot go unnoticed without compromising the current and future relationship of the parties, the legitimacy of the violated rule, and the wider social web in which the participants are enmeshed.”

Group apologies are especially important. Although current members of a group might bear little or no responsibility for past actions, a group apology makes clear the group's current moral orientation. Acknowledging past wrongs lays a marker for understanding and tracking current and future actions. According to Tavuchis,⁸ group apology is one of the most powerful types of apology because it puts the acknowledgment of past wrongs formally on record, thus opening the door to healing fractured relationships.

If the process of healing fractured relationships and correcting injustices were linear, it might follow a sequence beginning with apology, then reconciliation, moving to a period of building trust, and finally advancing to collaboration and partnership. But the process is not always linear; indeed, the AMA's apology⁷ builds on an increasingly strong NMA-AMA collaboration in recent years.

The chief aim in this matter is to keep moving forward on a path toward eradication of prejudice and its harmful effects and to achieve equality in society as a whole but especially in health care and public health. While some progress has been made, important goals have been established for the coming years.

First, the AMA has a definitive statement against discrimination in its bylaws: “Membership in any category of the AMA or in any of its constituent associations shall not be denied or abridged because of sex, color, creed, race, religion, disability, ethnic origin, national origin, sexual orientation, gender identity, age, or for any other reason unrelated to character, competence, ethics, professional status or professional activities” (available at http://www.ama-assn.org/apps/pf_new/pf_online).

Second, the AMA's current Code of Medical Ethics includes several opinions regarding nondiscrimination and equity that the AMA Council on Ethical and Judicial Affairs has developed in recent decades. For example, an opinion on civil rights and professional responsibility states that “Opportunity in medical society activities or membership, medical education and training, employment, and all other aspects of professional endeavors should not be denied to any duly licensed physician because of race, color, religion, creed, ethnic affiliation, national origin, sex, sexual orientation, age, or handicap.”⁹

Third, the AMA has policy that “supports increased diversity across all specialties in the physician workforce in the categories of race, ethnicity, gender, sexual orientation/gender identity, socioeconomic origin and persons with disabilities” and directs the association to advocate for funding to support (1) pipeline programs to prepare and motivate members of underrepresented groups to enter medical school, (2) diversity or minority affairs offices at medical schools, (3) financial aid programs for students from underrepresented groups, and (4) financial support programs to recruit and develop faculty members from those groups (AMA policies H-200.951 and D-200.985; available at http://www.ama-assn.org/apps/pf_new/pf_online).

Policies and pledges are important, but they are only a beginning. Meaningful actions and measurable outcomes must follow. To track progress, the AMA prepares a biennial report comparing the demographic characteristics (age, sex, and race/ethnicity) and the proportion of international medical graduates for all physicians and medical students, AMA members, the House of Delegates, the Board of Trustees, and AMA committee members and section leaders. Data for 2006 reveal areas of improvement but also persistent and sizable gaps. For example, the proportion of African Americans was low among all physicians and medical students (2.2%) but higher among alternate delegates (3.3%) and among committee members and section leaders (5.0%). Representation of women physicians within the AMA has generally improved from 1999 to 2006, when 4 of the 20 (20%) physician and medical student members of the Board of Trustees were women, but there were no African American trustees in 2006.¹⁰

Through the years, the AMA has formed several sections or committees for population segments that are underrepresented at various levels in medicine, including racial/ethnic minorities, women, young physicians, international medical graduates, and gay, lesbian, bisexual, or transgender (GLBT) physicians. These groups engage in efforts to increase the diversity of the physician workforce, provide opportunities for and training in leadership development, offer forums for networking and mentoring, and help the association develop policies and programs pertaining to their constituencies.

In 2004 the AMA, the NMA, and the National Hispanic Medical Association formed the Commission to End Health Care Disparities, a coalition of more than 50 state medical associations, medical specialty societies, and other health professional organizations working collaboratively to eliminate disparities in health care. The AMA and NMA cochair the commission and work together to plan and carry out its activities; the AMA provides staff and financial support. Commission objectives include (1) influencing government actions so as to curtail disparities in health care; (2) engaging health professionals and organizations in efforts to eliminate disparities; (3) improving the practice environment to foster effective efforts to eliminate disparities; (4) increasing the diversity of the health professional workforce; and (5) promoting collaboration between medicine and private industry on strategies to eliminate disparities.¹¹

The commission has completed a study on the implications of pay-for-performance and quality-reporting programs for health care disparities.¹² It also has adopted and invigorated the “Doctors Back to School” program. First developed by the AMA Minority Affairs Consortium, this program connects physician volunteers to students in underrepresented groups, from elementary schools to undergraduate colleges, to encourage these students to consider careers in health care.

Despite this progress, much more work needs to be done by all stakeholders in health care and public health—individually and cooperatively. Authoritative reports continue to document persistent disparities in health status and health care according to race and ethnicity.^{13 - 14}

Psychological research suggests that whites and African Americans tend to view changes in the racial milieu in different ways. Whites tend to see full equality of opportunity as an idealized goal, and they measure progress by comparing the present and the past, noting how far society has come; but African Americans and other nonwhites are more likely to see racial equality as a necessary condition for justice and to judge current racial inequalities against a future of equal opportunity, which still seems far off.¹⁵ The beliefs that society has come a long way and yet still has a long way to go are both correct. Viewing contemporaneous society and recent history from different perspectives, using different yardsticks, can help promote mutual understanding, healing, and reconciliation.

The medical profession must have diversity in the physician workforce—equivalent to that in the general population—and equity in health care delivery for all persons. A unity of purpose must be achieved among all physicians, and the associations that represent them, to make this envisioned future a reality. To some, whether looking back or looking forward, attaining equality of opportunity in medicine may seem an audacious goal, but it is not optional for the medical profession. It is within reach, and the nation will celebrate the day when racial harmony is achieved in health care for the benefit of patients, communities, and the medical profession.