Bioethics Forum Essay
Structural Racism, White Fragility, and Ventilator Rationing Policies
It’s been painful to watch health leaders twist themselves into moral knots denying that recently created ventilator rationing guidance will differentially affect Blacks, Latinx, and other people of color. On television, in newspapers, and on listservs, when the predicted disproportionate impacts of these policies are raised, some bioethicists-often white, stonewall. Or repeat a policy’s assertions that race, ethnicity, disability, etc. are irrelevant to care decisions. Or default to the intent of the policymakers.
“White fragility” is the term educator Robin DiAngelo coined to describe such behavior. This avoidance of dealing with race and racism stems in part, she says, from whites not understanding themselves as raced, not owning up to being the dominant racial group in the United States and to having racial privilege. White fragility is not new to bioethics, but it is highly visible now.
The inequitable racial landscape of the United States is hardly deniable. The effects of racism on health status and on access to health care are well documented. Comprehensive race/ethnicity data relevant to Covid-19 will likely affirm inequitable patterns in exposure, testing, and treatment, patterns that are already being observed by practitioners in some facilities and officials in some states.
Other bioethicists have been clear, at least in professional circles, that social inequities including structural racism do in fact shape crisis standards of care, that ostensibly “objective” measures of the likelihood of short and long term survivability depend at least in part on comorbidities that disproportionately affect people of color. And they acknowledge that such criteria will have life-threatening consequences when ventilators are scarce. To do otherwise would be to deny the very presence of racism in health care and medicine.
Last week I watched “Edge of the City,” a 1957 film starring Sidney Poitier, John Cassavetes, and Ruby Dee. At the movie’s end, white man after white man denies witnessing their white boss’s racist murder of a black co-worker. Denial of this man’s death was a denial of his life as well as a denial of the racism that led to his death. This interpersonal racism has a corollary in structural racism, which also kills.
What to do about structural racism in health care is a critical conversation that requires white people, as members of the dominant racial group, to sit with the uncomfortable reality that we have benefited from a racial hierarchy that has harmed others. It requires us to acknowledge that structural racism is present in health care, health policy, and public health; to understand that the intent of policymakers is less important than the effects of their policies. And to trust that those most affected by structural racism have crucial knowledge about effective strategies to reduce and end it. To begin that conversation, bioethicists must, at the least, stop denying that structural racism exists in health care policy and that it can kill.
Charlene Galarneau is a senior lecturer in the Department of Global Health and Social Medicine at Harvard Medical School’s Center for Bioethics and associate professor Emerita at Wellesley College’s Department of Women’s and Gender Studies.