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J Immigrant Minority Health (2010) 12:489495

DOI 10.1007/s10903-008-9210-y

ORIGINAL PAPER

The Neglect of Racism as an Ethical Issue in Health Care


Megan-Jane Johnstone Olga Kanitsaki

Published online: 18 November 2008


 Springer Science+Business Media, LLC 2008

Abstract Race and racism has been increasingly implicated in known disparities in the health and health care of
racial, ethnic and cultural minorities groups. Despite the
obvious ethical implications of this observation, racism as
an ethical issue per se has been relatively neglected in health
care ethics discourse. In this paper consideration is given to
addressing the following questions: What is it about racism
and racial disparities in health and health care that these
command our special moral scrutiny? Why has racism per se
tended to be poorly addressed as an ethical issue in health
care ethics discourse? And why, if at all, must racism be
addressed as an ethical issue in addition to its positioning as
a social, political, cultural and legal issue? It is suggested
that unless racism is reframed and redressed as a pre-eminent ethical issue by health service providers, its otherwise
preventable harmful consequences will remain difficult to
identify, anticipate, prevent, manage, and remedy.
Keywords Racism  Ethics  Health care 
Health services  Health professionals

Introduction
Health care ethics, by its very nature, involves values,
views, and propositions that invite and provoke controversy. Ethical issues such as abortion, euthanasia/assisted
M.-J. Johnstone (&)
School of Nursing, Faculty of Health, Medicine, Nursing
and Behavioural Sciences, Deakin University, 221 Burwood
Highway, Burwood, Melbourne, VIC 3125, Australia
e-mail: megan.johnstone@deakin.edu.au
O. Kanitsaki
RMIT University, Melbourne, Australia

suicide, end-of-life decision making, reproductive technology, genetic engineering, to name some, are all familiar
subjects of debate and disagreement in the health professional literature. A less familiar topic in health care ethics,
however, is that of racism. Just why racism as an ethical
issue has been overlooked in health care ethics discourse is
a matter for consternation.
Racism is a highly charged moral issue [1]. When
allegations of racism are made, even when justified, the
people concerned tend to respond with deep moral outrage.
Racism is also emerging as a highly charged health care
issue. Racism and its counterparts xenophobia, prejudice
and discrimination are being increasingly implicated in
racial and ethnic disparities in health and health care [2],
and in disparities in the safety and quality of health care of
ethnic minority groups [37]. As Smedley et al. [2, p. 494]
observe the racial experience has been, and remains, the
most intense in discriminatory levels and differential outcomes, especially with regard to health and health care.
When suggestions are made that racism is at least
implicated in, if not casually related to, racial and ethnic
disparities in health and health care, health service providers and researchers alike have tended to reject the idea
that racism is a problem here and instead have emphasised as causal explanations:
cultural and language barriers, a lack of consumer
health literacy and knowledge about health and social
support services, the impact of geographical location
and circumstances of migration on migrants financial
circumstances, service provider cultural insensitivity
and lack of cultural competency, a lack of agreed
standards guiding the delivery of culturally and linguistically appropriate services, and a lack of
understanding among community and government

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stakeholders of the importance of evidence-based


policy and practice [5, p. 110].
Accordingly, the issues of racism per se and the
(un)ethics of racial and ethic disparities in health and
health care have not been comprehensively addressed in
health care ethics discourse.
A key aim of this article is to draw attention to the
problem of racism as a fundamental ethical issue in health
care and to invite its redress. Building on a companion
article in which the spectrum of new racism and discrimination in health care is reappraised [7], brief attention is
given to addressing the questions: What is it about racism
and racial disparities in health and health care that these
commands our special moral scrutiny? Why has racism per
se tended to be poorly addressed as an ethical issue in
health care ethics discourse? And why, if at all, must racism be addressed as an ethical issue in addition to it being
positioned as a social, political, cultural and legal issue?
The Notion and Practice of Racism
Race and racism have been the subjects of critical theorising by the humanities and social sciences for several
decades now and there is nothing further to be gained by
rehearsing the ideas and findings of this theorising here
(see [1], [814]). Nonetheless, for the purposes of this
discussion, a working definition of racism is warranted. To
this end, the term racism is taken as referring to a highly
political process of racial ordering and othering that is
perpetuated by cultural elites on the basis of a given peoples language groups, religion, group habits, norms and
customs: including typical style of dress, behaviour, cuisine, music and literature, etc [10, p. 70]. A key premise
upon which this definition is based is that racism is fundamentally about power and, in particular, the ability to
construct others as different in order to exclude or ignore or
exploit them [14, p. 252]. Combating racism thus requires
considerably more than merely valuing diversity, overcoming xenophobia (a reflexive feeling of hostility to the
stranger or Other [10, p. 6], or advocating tolerance. It
also demands a deconstruction of the ideological and
material power inherent in racist discourse, structures and
practices [14, p. 25].
Racial Prejudice and Discrimination in the World
According to the United Nations Development Programme
(UNDP), more than 5,000 different ethnic groups live in
just 200 countries in the world today. The UNDP estimates
that in two out of every three countries there is at least one
substantial ethnic or religious minority group, representing
10 percent of the population or more [15, p. 2]. The UNDP

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further estimates that one in every seven of the worlds


population (around 900 million people) face some form of
discrimination because of their racial, ethnic or religious
identities [15, p. 6].
Racial Prejudice and Discrimination in Health Care
Although it should be otherwise, people from minority
cultural and language backgrounds experience both individual and institutional forms of racism in health care [16,
17]. This is so despite the best efforts of diversity advocates
to redress racially motivated discriminatory and prejudicial
practices in health care.
Over the past several decades, policy makers in multicultural countries such as Australia, Canada, New Zealand,
the UK, and the US (each of which have significant multicultural and multilingual populations) have given
considerable attention to developing and operationalising
numerous multicultural policies and programs (including
anti-racism and discrimination laws) aimed at achieving
health care equity, reducing health disparities, and ensuring
the equal participation of ethnic minority populations
(including immigrant, indigenous, refugee and asylum
seeker populations) in local health care services [2, 18].
Despite the gains that have been made as a result of
ongoing policy initiatives aimed at addressing the needs of
these populations, ethnic minorities are generally underserved by local health care and other social services,
experience unequal burdens of disease, confront cultural
and language barriers to accessing appropriate health care,
and receive a lower level and quality of care when they do
access health care compared to the average (majority)
population [26, 1820].
As previously indicated in the opening paragraphs of
this article, racial discrimination in health care is being
increasingly linked to racial and ethnic disparities in health
and health care. Researchers acknowledge that the causes
of racial and ethnic disparities in health and health care
may be explained by a complex array of socio-economic,
political and other factors [2]. What is particularly noteworthy about the racial and ethnic disparities in health and
care, however, is that they are remarkably consistent
across a range of illnesses and healthcare services [2, p.
5]. Moreover, socio-economic indicators do not explain all
of the differences noted, notwithstanding that the lower
socio-economic status of certain racial and ethnic groups
may be substantively linked to past and current discriminatory social policies and practices [3, 5, 2123].
Why Racism in Health Care Commands Moral Scrutiny
It is a truism that racism in health care is morally wrong
and should not be embodied in the beliefs and practices of

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either individual health care professionals or health care


institutions. There has, however, been relatively little
attention given to why racism in health care is morally
wrong, and why health service providers in particular may
have a special moral obligation to prevent its incidence
and harmful impact on the people concerned.
In keeping with the humanitarian ethos of health care
professionals, patients and their loved ones rightly expect
that when requiring and receiving health care they will be
treated in a non-discriminatory mannerthat is, they will
receive the care and treatment they need and will not be
discriminated against on the basis of their personal characteristics such as race, ethnicity, culture, religion,
spirituality, disability, age, gender, sexuality, economic,
social or health status [7]. There are strongly warranted
practical as well as moral reasons why the health professions have adopted this ethos.
Prejudice (literally to prejudge without adequate facts)
encompasses any belief (especially an unfavourable one),
whether correct or incorrect, held without proper consideration of, or sometimes in defiance of, the evidence [24,
p. 326]. Its corollary discrimination involves the unfair
treatment of a person, racial group, minority, and the like,
based on prejudice.
It is important to understand that discrimination can be
either direct or indirect [25]. Direct discrimination may be
held to have occurred when someone is treated less
favourably on the basis of the certain personal characteristics (e.g. age, gender, race, ethnic origin, nationality,
religion) and is adversely affected because of being treated
differentlynoting here that one does not have to had
acted intentionally or to believe that the act is discriminatory [25]. Indirect discrimination, in turn, may be held to
have occurred when norms, procedures and practices that
appear to be neutral, but whose application disproportionately affects members of certain groups [25, p. 403].
(Unlike direct discrimination, however, indirect discrimination may be justified if the policy or rule is reasonable
and relevant to particular circumstances [26, p. 7]).
Racism in health care is a special moral wrong because
it violates a fundamental and universally accepted principle
of health professional ethics, notably: to do no harm.
Racism and the prejudice it motivates also contravenes the
principles and standards of evidence-based practice (as just
noted above, by its very nature, racial prejudice is to prejudge without evidence). In either case, the kinds of attitudes and behaviours that are commonly associated with
racist and racialised practice (e.g. antipathy, avoidance,
ignoring, disengagement, rejection, indifference) are the
very antithesis of those required and expected in an ethical
and therapeutically effective clinical relationship and, if
not corrected, can seriously threaten patient safety and
quality care [2, 6, 7, 27, 28].

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Racism and Harm


Irrespective of whether it is direct or indirect, intended or
unintended, racism harms people in enduring ways. In
order to better understand the harms of racism, an examination of the notion of harm itself is required.
According to the noted American political and social
philosopher Joel Feinberg [29], at its most basic, harming
someone involves invading, violating, thwarting, or setting
back that persons significant welfare interests to the detriment of their well-being. A persons interests, in this
instance, maybe taken to mean a miscellaneous collection,
consist[ing] of all those things in which one has a stake
together with the harmonious advancement of those
interests [29, p. 34]. Interests, in turn, are morally significant since they are fundamentally linked to human wellbeing; specifically, they stand as a fundamental requisite
(although, granted, not the whole) of human well-being
[29, p. 37]. Well-being, in turn, can include interests in:
continuance for a foreseeable interval of ones life,
and the interests in ones own physical health and
vigour, the integrity and normal functioning of ones
body, the absence of absorbing pain and suffering or
grotesque disfigurement, minimal intellectual acuity,
emotional stability, the absence of groundless anxieties and resentments, the capacity to engage
normally in social intercourse and to enjoy and
maintain friendships, at least minimal income and
financial security, a tolerable social and physical
environment, and a certain amount of freedom from
interference and coercion [29, p. 37].
The test for whether a persons interests and well-being
have been violated, set back, thwarted or invaded rests on
whether that interest is in a worse condition than it would
otherwise have been in had the invasion not occurred at all
[29, p. 34].
When individuals and groups are treated prejudicially in
health care because of their racial, ethnic or cultural
characteristics they may be (and often are) left psychogenically distressed (e.g., emotionally distressed, anxious,
depressed and even suicidal), physically harmed (e.g., iatrogenically ill and injured), and in a state of needless
suffering. In such instances, our reflective commonsense
tells us that the interests of the individuals and groups
concerned have been violated and the people themselves
harmed. As Feinberg [29, p. 17] explains, the violation of a
persons welfare interests renders that person not only
violated but very seriously harmed indeed [since] their
ultimate aspirations are defeated too.
Racism in health care can cause people to be very
seriously harmed indeed. When harm is caused by racism
and racialised practice, the health professional ethic of do

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no harm is violated and the very work and telos (purpose)


of health care practice undermined. It is for this reason that
racism qua racism deserves our deepest moral scrutiny.
Why Racism has been Neglected as Ethical
Issue in Health Care
Given the significant and preventable moral harms caused
by racism in health care, the question arises as to why,
relative to other perplexing ethical issues in health care,
racism has been poorly addressed and even ignored as an
ethical issue in health service and health professional discourse? There are a number of reasons for this, including:
the failure by philosophers and bioethicists to examine
racism as an ethical issue and to show why it is morally
wrong and hence ought to be rejected; the illusion of nonracism in health care, that is, a genuine belief among
health service providers that racism is not an issue any
more; a subconscious association between raising awareness of the issue of racism in health care and
whistleblowing; and related to all these considerations, an
overwhelming sense that the issue is just too hard to deal
with. These reasons are briefly considered under separate
subheadings below.

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been termed elsewhere as the health care illusion of nonracism, which is defined as an illusion that rests on the
frequently articulated belief that there is no racism here
and racism is not an issue anymore [18, p. 178]. The
basis of this illusion and the reasons for its durability are
complex. Nonetheless, we suggest that the following processes have played a significant role in maintaining this
illusion: a misguided view among health service providers
of health care being an institutional culture of no culture;
the deeply conservative nature of medicine and allied
health professional cultures; a biased tendency by some
health service providers to misperceive and overestimate
their capacity to be ethical; moral passivism; and the
implementation of Trojan horse cultural diversity policies
in health care. These processes are summarised below:

The Lack of Response by Philosophers and Bioethicists


Racism has been described as being an extraordinarily
robust worldview and, as such, one that merits deep
philosophic scrutiny [30, p. 426]. Even so, there has been
less than a robust response from philosophers and bioethicists to questions about conceptions of racism and why, if
at all, racism is morally wrong and therefore ought to be
rejected. The lack of philosophic and bioethics discourse
on the topic of racism is mirrored in the health professional
literature, which otherwise relies on the cross-fertilisation
of knowledge and ideas from the disciplines of philosophy
and bioethics to inform the identification and redress of
emergent and extant ethical issues in health care. Although
recent attention has been given to the oversight of racism as
both a philosophic and ethical issue [1, 11, 30], it remains
poorly addressed by these academic disciplines. There is
scope to suggest that until there is a shift in attention in
regard to this matter, it will remain poorly addressed in
health care ethics and related policy and practice processes.

The Illusion of Non-Racism in Health Care


Another possible reason racism has been overlooked as an
ethical issue in health care relates to the genuine belief
among health service providers that racism no longer
exists in health care and that if racist practices do exist,
they cause little or no harm [31, p. 48]. This stance has

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Health care as an institutional culture of no culture:


The institutional culture of medicine (which arguably
stands as the dominant cultural force and influence in
health care domains) has long been portrayed as a
culture of no culturethat is, a community defined
by the shared cultural conviction that its shared
convictions were not in the least cultural, but, rather,
timeless truths ([32, p. 556], citing [33]). Although
other allied health professions (especially the nursing
profession) have sought historically to distance themselves from what is commonly referred to as the
medical model of health care, there is a sense in
which they too operate under the illusion of an
institutional culture of no culture. This illusion powerfully fosters and sustains the false belief that health care
practice is objective, impartial, value neutral, and
true. Hence, any suggestion of health care practice
being prejudicial and discriminatory is considered to be
not only absurd and misguided, but an offensive
untruth.
The conservative nature of medicine and associated
health care service delivery: The institution of biomedicine, which is a driving force in health care
domains, is extremely conservative and habituated as
an enterprise. Whether intentionally or unintentionally,
biomedicine has playedand continues to playa
significant role in conserving, employing and disseminating racial and gender-biased conceptions in its
theory and practice [34, p. 2253]; see also [35]. This
conservatism is strongly reflected in the allied health
professions as well, which remain strongly partnered
with biomedicine as an enterprise.
A biased tendency by health service providers to
overestimate their capacity to be ethical: Health care
professionals, like other people, are not immune to the
biased tendency to misperceive, overestimate and
engage in self-deception about their moral capacity to

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think and be ethical when evaluating and responding to


unethical behaviours (including racism) in either
themselves or others [3641]. The implications of this
are that health care professionals might genuinely
understand and accept that racism occurs in health care,
and believe that it is wrong. Nonetheless, they might
also yield to various psychological forces that promote
self-deception and, as they trade off self-interest with
ethical principles, come to falsely believe that they
have not engaged in or promoted racism or racialised
practices in health care when in fact they have [7, 28].
Moral passivism: Individual health service providers
might subscribe to the highest moral ideals of their
respective professions (especially those proscribing
prejudice and discrimination in their practice). Nonetheless, they may never lift a finger to counter the
injustices of racism or racialised practices in health care
contexts, or support in a personal and individual way
related reform movements aimed at improving the
status quo [42]. Because of having studied ethics as part
of a formal professional or continuing education
program, and having agreed to the codified ethical
standards of their profession, morally passive health
care providers believe that they have discharged their
moral responsibilities to stakeholders and need take no
further action as morally accountable professionals.
Trojan horse cultural diversity policies: The past
several decades has seen the development and operationalisation of what might be broadly described as
cultural diversity policies and processes in health
care, particularly in the USA, UK, Canada, Australia,
New Zealand and several European nations [18]. There
is some suggestion, however, that these policies have
been hijacked by cultural conservatives and used as a
Trojan Horse to foster a false sense of making progress
and accomplishment apropos that previous bad attitudes (e.g. intolerance of and even hostility toward
cultural differences and diversity) and associated
behaviours (prejudice and discrimination) detected in
health care have now been fixed, when in fact they have
not been [18].

Racism as Whistleblowing
Proposing the existence of racism and racialized practices
in health care is an inherently risky thing to do. This is
because such a proposition is a form of whistleblowing.
The risks of such whistleblowing can be far reaching.
Among other things, drawing attention to the incidence and
impact of racism in health care could result in bad publicity, complaints, and costly legal proceedings by those
affected. Meanwhile, minority racial and ethnic groups

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who are already reluctant users of mainstream health care


services and who are already underserved by themmight
become even more mistrustful of health service providers
than they already are and further avoid needed care and
treatment. Worryingly, it could also risk alienating conscientious health professionals and health care
organisations who are working hard to make a difference
and to improve both the cultural consciousness and cultural conscientiousness of the health care system.
Racism as Too Hard to Deal With
Because of the demonstrable difficulties involved, identifying and addressing racism as an ethical issue in health
care might be regarded by some as being just too hard. In
addition to being extremely controversial (nothing prickles
people more than to accuse them of racism even when
justified), as Stone and Dula [31, p. 48] point out, it may
also be economically costly:
Seriously addressing biased attitudes and actions
requires that institutions divert limited energy, costly
time, and precious resources from other important
[sic] programs.
In political climates that are hostile to multiculturalism
and ethnic diversity, the effort that is required on the part of
individuals to mobilise the resources necessary might not
only be onerous, but may entail actions that some might
regard as being beyond what is reasonable to expect.
Addressing Racism as an Ethical Issue in Health Care
If racism and the unacceptable harm that it causes in health
care domains are to be correctly identified, effectively
anticipated, carefully managed and appropriately remedied,
these need first to be framed as an ethical issue that warrants our deepest moral scrutiny. Moreover, unless racism
in health care is explored and understood as an ethical
issue, health service providers will not be well positioned
to know and understand whether their professional ethics
and actions will result in harm to others, and will enable the
kind of health professional relationships that allow for the
flourishing of good rather than evil, trust rather than fear,
difference rather than sameness, healing rather than surviving [43, p. 487].
It is acknowledged here that redressing the (un)ethics of
racism in health care will inevitably give rise to various
(and some might say, intolerable) tensions in the field.
While the tensions created might be uncomfortable and
even painful, this in itself is not sufficient to justify sidestepping the issue. This is because, at the very least, they
may prompt people to reflect deeply about the issue. In the
case of health care providers who are conscientious, the

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tensions evoked may encourage them to be careful and,


where necessary, to take appropriate measures to curb
either their own or others inclinations to engage in racialised practices and to reduce the impact of the ill effects of
such practices. In the case of those who remain resolute in
their racism, the tensions will signal the need for broader
measures to be taken and for a higher level of intervention
(including legal sanction and professional censure such as
professional deregistration) to assist in reducing the incidence and harmful impact of the various forms of racism
that may have unacceptably found expression in a given
health care context.
It is also important to remember, as the late Martin
Luther King [44] reminds us, that creating tension is an
important part of anti-racist work. In his famous Letter
from Birmingham Jail (dated 16 April, 1963), King writes:
I must confess that I am not afraid of the word
tension. I have earnestly opposed violent tension,
but there is a type of constructive, nonviolent tension
which is necessary for growth. Just as Socrates felt
that it was necessary to create a tension in the mind so
that individuals could rise from the bondage of myths
and half-truths to the unfettered realm of creative
analysis and objective appraisal, we must see the
need for nonviolent gadflies to create the kind of
tension in society that will help men [sic] rise from
the dark depths of prejudice and racism to the
majestic heights of understanding and brotherhood
[44, pp. 6768].

Conclusion
This article has argued that racism as an ethical issue per se
and its moral implications for health service providers are
neglected issues in health care ethics discourse. In an
attempt to redress this oversight, attention has been given
to briefly exploring: what it is it about racism and racial
disparities in health and health care that these command
our deepest moral scrutiny; why racism per se has tended to
be poorly addressed as an ethical issue in health care ethics
discourse; and why, if at all, racism ought to be addressed
as an ethical issue in addition to its positioning as a social,
political, cultural and legal issue. It has been suggested that
unless racism is reframed and redressed as a pre-eminent
ethical issue by health service providers, its otherwise
preventable harmful consequences will remain difficult to
identify, anticipate, prevent, manage, and remedy. Health
care professionals in turn will find themselves in a less than
ideal position from which to ensure that their clinical
encounters with others (whose cultural life ways and

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language they may not share or understand)even when


well intendedwill not result in prejudicial harm being
caused.

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