Special Section: Bioethics and Health Disparities Debating the Cause of Health Disparities Implications for Bioethics and Racial Equality

In 2002, the health arm of the National Academy of Sciences, the Institute of Medicine (IOM), scientifically documented widespread racial disparities in healthcare and suggested that they stemmed, at least in part, from physician bias. Its 562-page report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, noted that, although these disparities are associated with socioeconomic status, the majority of studies it surveyed ‘‘find that racial and ethnic disparities remain even after adjustment for socioeconomic differences and other healthcare access-related factors.’’ As directed by Congress, the IOM committee defined ‘‘disparities’’ in healthcare as ‘‘racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention’’ (pp. 3–4). Unequal Treatment concludes that, after factoring out these access-related differences, remaining disparities can be attributed in part to discrimination by the medical profession—physician prejudices, biases, or stereotyping of their minority patients. Some commentators took offense at the report’s charge of racial bias. It was unfair, they argued, to suggest that blatant racial prejudice, as was demonstrated in the Tuskegee syphilis experiment, for example, still lingered in contemporary medical care. ‘‘I would stress that the attitudes of physicians today have shown a true revolution from those that permeated the generation or two ago,’’ wrote University of Chicago law and economics professor Richard Epstein. ‘‘It is a shame to attack so many people of good will on evidence that admits a much more benign interpretation.’’ The ‘‘benign’’ interpretations offered by critics were that racial disparities stem from patient behavior, cultural difference, biological difference, and economic inequality. Each of these explanations sounds familiar to historians of race and health in America. Although racial disparities in health are firmly established, pinpointing their cause has been controversial. In this article, I challenge recent claims that racial health disparities are caused by race-based genetic difference or race-neutral economic difference on grounds that both explanations ignore the roots of health disparities in social inequality. I develop my argument by examining the controversy surrounding the Institute of Medicine report on racial bias in healthcare,