NOBIS, NATHAN, Ph.D.
Assistant Professor, Morehouse College; Morehouse School of Medicine,
Department of Philosophy; Community Health and Preventative Medicine
Annette Dula is one of few African American bioethicists in the United States who has written extensively on racial aspects of bioethics, including those related to health disparities among different races. This article reviews philosophical and bioethical aspects of Dula’s writings, in particular those aspects that offer what might be called a “radical critique” of mainstream bioethical thinking and practice, and offers some criticisms and suggestions for development of the research agenda set forth by her work.
“The master’s tools will never dismantle the master's house.”
– Audre Lorde
“The master’s tools will dismantle the master’s house.”
– Åsa Andersson
In analytic philosophical ethics there is a wealth of discussion and argument concerning global or absolute poverty and health disparities inspired, in large part, by Peter Singer’s now classic 1972 article “Famine, Affluence, and Morality.”1, 2 Singer argued that, given some facts about poverty, the effectiveness of aid, and a simple moral principle (“If it is in our power to prevent something bad from happening, without thereby sacrificing anything of comparable moral importance, we ought, morally, to do it” 1[p. 231]), we are morally obligated to provide substantial aid to address global poverty and its poor results for health. This essay helped put moral concerns about the poor and underserved in (for most Western readers) far-off countries on what we might call the philosophical radar and made this a standard topic in practical ethics teaching and research.3
In contrast, domestic (U.S.) poverty and health disparities, especially where racial dimensions are a concern, has not become a comparably hot topic in analytic philosophical teaching and research: for example, a survey suggests that it is not a core topic in many Introductory Ethics or Moral Problems courses.3 Those who seek philosophical resources on these topics (where philosophical is understood relative to the methods and argumentative standards practiced in, among other contexts, mainstream philosophy departments) using the typical methods of scholarly research that philosophers often use will come up nearly empty-handed. This is not to say that no such argumentative moral reflection exists, but that, at least, it is not readily or easily found using typical philosophy research methods; at least, I have had difficulty. This is a reason that bioethics is often best done in an interdisciplinary manner, since scholars from different disciplines and contexts inform each other about different resources, share them, and learn from each other.
Fortunately, however, there is some philosophical writing on domestic health disparities. One of the few thinkers whose writings emerge time and time again using standard philosophical research methods is Annette Dula. Dr. Dula has been associated with a number of academic institutions, including Tuskegee University, the University of Colorado’s Center for Values and Social Policy and its Women’s Studies department, and others. She is the author of dozens of academic publications, most of which have to do with ethics and minority, poor and/or underserved populations.
Since Dula’s work is so prominent, i.e., it is likely to be among the first found in a philosophical search, and since she has developed such an extensive body of work, here I offer a brief review and philosophical critique of some of her more prominent writings and arguments on the topic of domestic health disparities. I focus on the ethical or moral aspects of her writings that offer what might be called a “radical critique” of mainstream bioethical thinking and practice – what some might call the “master’s tools,” namely, mainstream Western philosophy – and argue that this critique is unconvincing and should be resisted for both theoretical and practical reasons. I hope that this review will encourage others to engage these pressing issues with greater urgency and develop new, better moral arguments concerning poor and underserved populations with which to engage scholars, students, and society as a whole.
What Do We Want in a Moral Argument About Health Disparities?
I begin by asking what we might want from moral reflection on health disparities, that is, what do we want from a philosophical bioethicist on the issue of health disparities?
While bioethics often involves more subtle and nuanced tasks, the most obvious and initially important task for a bioethicist who addresses the topic of domestic health disparities would be to offer a conclusion that some action(s) or state(s) of affairs concerning poverty and health is morally wrong or unjust, give moral reasons or arguments to support that conclusion and respond to objections and arguments for contrary conclusions. So we would hope for conclusions about what individuals and groups are treated wrongly, unfairly or unjustly, which policies are morally wrong or unjust, what conditions or states of affairs are unjust, and, most importantly, moral reasons and arguments for why we should believe these conclusions. Implied by each of these conclusions would be a conclusion about who exactly is morally obligated to do something concerning this wrong or injustice, what exactly they are obligated to do and, again, why.
Such arguments will typically involve the presentation of factual, empirical, or scientific information concerning an issue, the introduction and defense of a moral principle (or principles) that propose, at least, a sufficient condition for an action being wrong or a society being unjust or some other moral evaluation, and the claim that, given these facts, the principle applies to the action and so is morally wrong: both factual and moral premises are typically necessary for moral arguments concerning practical moral and social issues.4
Of course, one can also engage bioethics and health disparities by arguing in moral favor of the status quo and by attempting to debunk arguments in favor of progressive change: if done well, this subversive activity of attempting to prevent or delay moral progress will involve the same process of identifying moral conclusions, offering reasons why these conclusions should be accepted (at least, according to their advocates) and raising and responding to objections.
I mention these bioethical goals and an overview of methodology so that we might consider evaluating Dula’s work in light of them. She clearly believes that we are morally obligated to do something about domestic health disparities, and we might expect that this bioethical reflection concerning these domestic health disparities would proceed in a manner analogous to how bioethics and global health disparities is typically discussed: relevant factual information about poverty and health are presented, a conclusion about what we are (or someone is) morally obligated to do regarding these facts is presented and claims about why this is so are developed and defended.
I will argue that Dula’s efforts at this task are regrettably disappointing: we don’t get the clearest, most directed arguments on the exact questions of what exactly anyone is morally obligated to do concerning domestic health disparities and why this is so that we might hope for. Again, I offer this critique with the hopes that doing so will lead others to build upon Dula’s discussion to create stronger, more complete arguments concerning domestic health disparities that will have greater impact upon positive, progressive change.
Dula’s Writings: An Overview and Philosophical Critique
Nearly all of Dula’s writings include a presentation of the facts about the health status of African Americans: a wealth of factual information is presented to show that African Americans’ health tends to be worse than Whites’ health by many measures. Since there is more current information and data to document health disparities than Dula’s, I will very briefly review this newer information. The CDC (Centers for Disease Control and Prevention) offers this brief summary:5
“The health disparities between African Americans and other racial groups are striking and are apparent in life expectancy, death rates, infant mortality, and other measures of health status. For example:
In 2007, the average American could expect to live 77.9 years, while the average African American could only expect to live 73.6 years, compared with 78.4 years for the average White American.
Compared with any other population from 2005-2007, African Americans had the largest age-adjusted death rate for all causes and for specific death rates due to heart disease, stroke or cancer.
The U.S. infant mortality rate for mothers of all races was 6.8 deaths per 1,000 live births. while the rate for white mothers was only 5.6 deaths per 1,000 live births, the rate for African American mothers was 13.2 deaths per 1,000 live births.
Factors contributing to poor health outcomes among African Americans include discrimination, cultural barriers, and lack of access to health care.
The 2011 CDC Health Disparities & Inequalities Report provides an abundance of readily available information, as do many other sources.6,7,8,9
Dula routinely notes that there are a variety of explanations or possible explanations to account for some side of health disparities:10 [p. 195], 11 [pp. 13-14], 12 [p. 350], 32 why is it the case that African Americans’ health tends to be worse than Whites’ health? Possible explanations that Dula discusses include: biological differences, beliefs that influence health-related behaviors, lifestyle choices (including forced choices, or a lack of choices), environmental factors, stress, the consequences of educational and socioeconomic status, health care access, including the quality and quantity of case, poverty, and—most interestingly —racism and unjustified discrimination of various kinds, among other causes.
Dula does not review any literature that attempts to identify how much various particular factors might contribute to a health disparity, i.e., she does not attempt to engage the daunting task of quantifying the differing causes of particular and general health disparities.13,14,15,16 Such estimations would be important to finding our way out of health disparities: knowing what causes them, and what level of influence different causal factors have, is vital to introducing new causes to lessen and eliminate health disparities.
Thus, Dula’s writings typically have a factual component in that they review data on health disparities and at least mention possible causes and contributing factors to the existence and continuation of health inequalities. While this kind of information is essential for practical bioethical arguments, my interest here is what specific moral considerations, i.e., moral premises or principles, she conjoins with these factual data to support a moral judgment about what anyone is morally obligated to do regarding these disparities and why. Thus, I turn to a focus on the specifically moral, ethical or philosophical aspects of her articles.
In a 1992 article “Yes, There are African American Perspectives on Bioethics,” published in a collection African American Perspectives on Biomedical Ethics, Dula advances the idea of an African American “perspective” on bioethics.10 She seems to argue that this is either useful or necessary to address the “unequal health situation” of African Americans.10 [p. 195] I argue that her call for bioethical re-orientation is unconvincing: it should be resisted for both theoretical and practical reasons.
Dula claims that “most African American philosophers have always been concerned with social injustices” 10 [p. 196] and so health disparities should be addressed by appeal to “its own authorities” such as “W.E.B DuBois, Alain Locke, William Banner, Leonard Harris, Laurence Thomas, and others.” 10 [p. 196] She asserts that “mainstream” philosophers have tended to not advocate for social change of the kind needed to address health disparities and that “mainstream philosophy,” such as the classic moral theories of Mill’s utilitarianism (which focuses on promoting happiness and well being and reducing misery) and Kant’s ethics (which focuses on respecting others as inherently valuable ends in themselves and acting in ways we would will others to act), should be eschewed in favor of African American philosophy. She concludes that “African American philosophy is an appropriate source for bioethics in general and African American bioethics in particular.” 10 [p. 196]
While I do not dispute that African American philosophical thought could be a basis for critiquing health care injustices, Dula could have proven this by identifying specific aspects of DuBois, Locke or any of the other figures she mentions that are especially relevant to bioethics and contemporary health disparities. 17 This scholarly demonstration of the potential bioethical relevance of these thinkers, which has never been done as far as I know, would have proven the utility in her proposal and shown why any of these thinker’s work might serve as a better foundation to critique health disparities than, say, Kantian – e.g., Rawlsian 18, 19, 20 (which judges actions and policies from behind a “veil of ignorance,” so we must consider how each individual is affected by them) – and Millian moral theories and other so-called mainstream hypotheses about what makes actions and policies wrong and unjust that can fruitfully be applied to health disparities issues.
While I believe that Dula’s impression that contemporary Euro-American philosophers fail to engage social ills and injustices is factually mistaken 21, 22, 23, 24 and she offers no substantial evidence to support these impressions, clearly they have developed the theoretical resources to explain, or at least try to explain, why domestic health disparities are wrong and unjust and what it is about the treatment of African Americans, among other groups, that makes it morally wrong.25 While Dula reviews many historical wrongs done to African Americans (e.g., forced sterilization, the Tuskegee Syphilis Experiment 10 [p. 197-200]), she does not seem to offer any particularly deep explanation why these actions were wrong.
Perhaps this is because it is now just obvious that these actions were wrong, but presumably this wasn’t the case then and, given the current existence of health disparities along racial lines, many contemporary people are not convinced of the wrongness of certain kinds of inequalities: for them, it’s not obvious that something should be done, just as—for most people— it’s not obvious that something should be done concerning global or absolute poverty and health disparities, which often cross racial lines as well.26
Since Dula does not offer much of an explanation why something should be done, i.e., moral-theoretical insights into contemporary health disparities or moral principles that might be used to explain why various kinds of change are morally required, this is disappointing. She doesn’t demonstrate how African American philosophy can help in this task and potentially and needlessly create divisions between health disparities advocates and so-called “mainstream” philosophers and bioethicists who potentially have a lot to contribute to addressing health disparities, especially in terms of, in light of their understanding of the factual issues or the understanding that they could gain, developing a moral imperative to engage the issues.27, 28
The next article by Dula I will discuss is “Bioethics: The Need for a Dialogue with African Americans,” was published in the 1994 collection It Just Ain't Fair! The Ethics of the Healthcare for African Americans.”11 An earlier 1991 version of this paper was published in a healthcare journal that focuses on the poor and underserved.12
This paper advocates broadening the “demographic makeup of bioethicists”11 [p. 11] to include more African Americans and other under-represented groups, since most bioethicists are White, middle-class males. This “inclusion of a broader range of perspectives” 11 [p. 12] would be valuable insofar as different groups tend to be more familiar with morally relevant factual information concerning the health care status and, potentially, ill-treatment of each group: e.g., Black women would in many ways have greater understanding of their own health care status and ill-treatment than White men would (and vice versa): whether different groups’ lack of knowledge and understanding of other groups’ plights is culpable ignorance or not is a further question to be explored. However, broadening the demographic of bioethics would surely broaden the range conclusions about what should be done that are discussed and provide better understanding of the empirical information relevant to why this is so.
Concerning why, morally, health care disparities should be addressed, I believe Dula’s response is again underdeveloped. First, she again does not offer much of a deep moral explanation why various disparities should be addressed: she details various wrongs done to African Americans and other minority groups but does not explain why they were wrong or offer guiding principles to address and avert future wrongs. Second, she writes, “even though all bioethicists would do well to examine the thinking of such philosophers as Alain Locke, Lucius Outlaw, Anita Allen, Leonard Harris, W.E.B. Du Bois, Bernard Boxill, Angela Davis, Cornel West, William Banner and Jorge Garcia, references to the work of these African Americans are rarely seen in the bioethics literature” 11 [p. 14] But she herself does not cite the work of these thinkers in building a moral case in favor of addressing health disparities so, again, it is not explained why an African American philosophical perspective (if there really is such a thing: “essentialist” doubts exist that there are moral-theoretical beliefs reliably correlated with racial membership) might be more useful in addressing health disparities than any mainstream philosophical ethics.27, 28, 29
The next essay I discuss is “Racism and Health: A Medical Ethics Issue,” written for a specifically philosophical volume published in 2003. 30 Here Dula reviews empirical data and social science research to “demonstrate that the poor health of African Americans is consequence of institutionalized racism in the health care system and in our larger social and economic arrangements.” [p. 349] She again documents many inequalities in the health care status of African Americans and reviews factors that actually or potentially contribute to this.
In her essay’s final section, entitled “An ethical solution: what are we to do?”[pp. 354-357] Dula specifically address moral-theoretical concerns: morally, what should be done about disparities and why? She pits a “universalist or colorblind morality against a morality that promotes and values diversity, multiculturalism and difference.” [p. 354] This distinction is not well explained and no specific theories or theorists in each camp are identified. Universalists, however, are said to think that “all humans are essentially the same and therefore ought to be treated the same way.” [p. 354] If this is “universalism,” then it can’t be right since everyone recognizes that people have some different needs and this should result in some differences in treatment: e.g., children have different needs than adults, women have different needs than men, sick people have different needs than healthy people and so forth. 31 Universalist principles, in the sense of principles that apply universally, are criticized because they can be misapplied, but it’s no fault of, say, Kant’s Categorical Imperatives or Utilitarian Principles25 or principles chosen behind Rawl’s “Veil of Ignorance” thought experiment18 that people sometimes fail to apply them correctly. All practical ethicists recognize the importance of identifying the details of morally relevant facts which vary by the case, person and group, not just any theoretical perspectives that focus on diversity, multiculturalism and difference.4
Dula concludes that both perspectives have value: universalists might argue for a “decent minimum of health care and equal distribution” 30 [p. 355] whereas the other perspective might, interestingly, support a kind of race-based “affirmative action” for health care.[p. 356] While I wish Dula had developed this affirmative action proposal in greater detail, she acknowledges that there are theoretical and practical challenges with it. She ends with, “Applying both a universalist and a difference approach could improve the health of all Americans.” [p. 357]
Since these approaches were, in my judgment, not well-defined or distinguished, some attempts at doing this were implausible, and few actual moral theories seem to fit these categories, I suggest that this distinction should be avoided in favor of a more straightforward, “What are we to do and why?” without concern for categorizing the “why” unless that seems important for any practical or theoretical reason, which it does not: at least, Dula does not explain why it does.
Finally, Dula has a 2004 bioethics encyclopedia article on “African American Bioethics.”32 In it she reviews empirical data on health disparities and hypotheses to account for the data, including racism. She also reviews historical and recent cases of African Americans being treated wrongly and unjustly. In the final section of the article, “The Colorblindness of Bioethics,”[pp. 290-291] Dula urges that there be more non-white bioethicists, since their experience and concerns would broaden the set of commonly engaged issues in bioethics. She reports some positive changes for diversity in bioethics:
More mainstream bioethicists are stepping outside their traditional role as white bioethicists, to consider race, racism, and white privilege as a valid bioethics concern. Bioethicist Catherine Myser—in an article dedicated to the late African American bioethicist Marian Secundy—argues in the 2003 Spring issue of the American Journal of Bioethics that the cultural construction of bioethics in the United States has not sufficiently questioned the dominance and normativity of whiteness.[*] The September–October 2001 issue of the Hastings Center Report also presented several articles on race and bioethics, including pieces by historian Susan Reverby and bioethicist Lawrence Gostin. Editor Greg Kaebnick comments on the movement of bioethicists to consider little talked about topics like race.[pp. 290-291]33
This article, unlike the previous writings, does not advocate any need for a moral-theoretical shift away from mainstream moral theories and towards African American sources. Dula concludes: “This discussion is meant not to vilify mainstream bioethics, but to show the need for a perspective and interpretation that focuses on bioethics issues that have a unique relevance for African American populations.” 32 [p. 291]. Thus, this more recent paper wisely avoids theoretical distinctions and divisions that are, in my judgment, dubious and imprudent.
In conclusion, I have reviewed some of Dula’s more prominent writings on bioethics and health disparities. Although I commend that they present the factual data on health disparities and review explanations for what causes them, I have repeatedly criticized Dula for not providing strong or deep moral explanations for why certain actions and policies towards and concerning various minority groups are wrong and unjust. If her intent was not to provide such explanations, or she thinks they are not important or necessary, the natural question is, “Why not?”
One might reply that it’s just “obvious” that certain past treatment of minorities was wrong and so no deep explanation is required. While I am sympathetic to that response, clearly not all people found, and find, it obvious that these actions and policies were wrong: a deeper explanation of why it was, and is still so, would help these people, and would certainly help the cause in addressing health disparities. Looking to the future, these deeper moral explanations would help guide us in defending our views about the various actions and policies that individuals, different groups and societies and our governments are morally obligated to do concerning health disparities.
Dula also repeatedly expresses the desire that more bioethicists concern themselves with domestic health disparities. I have suggested that, since global health disparities has become a core topic in bioethics and moral philosophy, those concerned with domestic health disparities should model their discussion after global concerns by:
1. presenting the morally-relevant factual information concerning domestic disparities;
2. identifying what explains or causes these disparities; and then, most importantly,
3. presenting conclusions about what morally ought to be done (and by whom); and
4. why, from a moral point of view, this ought to be done; and
5. defending one’s point of view from critical questions and objections.
Imposing a structure such as this on bioethical arguments concerning health disparities would make them all the more inviting and engaging to bioethicists of all experiences and persuasions, which could only have positive results for everyone, most importantly, people who suffer due to health inequalities.
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8 Kaiser Family Foundation. Minority Health. Available at http://www.kff.org/minorityhealth
9 Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press, 2002.
10 Dula A. Yes, There are African American Perspectives on Bioethics. In: Flack H and Pellegrino E, eds. African American Perspectives on Biomedical Ethics. Washington, DC: Georgetown University Press, 1992.
11 Dula A. Bioethics: The Need for a Dialogue with African Americans. In: Dula A and Goering S, eds. It Just Ain't Fair! The Ethics of the Healthcare for African Americans. Santa Barbara: Praeger/Greenwood Press, 1994.
12 Dula A. Toward An African American Perspective on Bioethics. Journal of Health Care for the Poor and Underserved. 1991 Fall; 2, 2: 259-269.
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29 Garcia J. Revisiting African-American Perspectives and Medical Ethics. In: L Prograis & E Pellegrino, eds. African American Bioethics: Culture, Race, and Identity. Washington, DC: Georgetown University Press, 2007.
30 Dula A. Racism and Health: A Medical Ethics Issue. In: Lott T and Pittman J, eds. A Blackwell Companion to African American Philosophy. London: Blackwell, 2003.
31 P Singer. Equality and its implications. In: P Singer. Practical Ethics, 3rd ed. New York: Cambridge, 2011.
32 Dula A. African American Bioethics. In: Post S, ed. Encyclopedia of Bioethics, 3rd ed. New York: Macmillan Reference USA, 2004: 287-292.
33 For a critical reply to Myser see R Baker. Balkanizing Bioethics. American Journal of Bioethics, Spring 2003, Vol. 3, Number 2, pp. 13-14.
Sources of funding: This work is supported (in part) through the U54 Morehouse School of Medicine /Tuskegee Institute / University of Alabama, Birmingham CCC Partnership Grant, Grant 2U54CA118948-06 from the National Cancer Institute.
Disclaimers: The author has no conflicts of interest or previous publications on this research project to declare.
Nathan Nobis is an Assistant Professor of Philosophy, Morehouse College, in Atlanta, an Adjunct Assistant Professor of Community Health and Preventative Medicine, Morehouse School of Medicine, and an adjunct professor of Animal Studies, Humane Society University, Washington, DC. He teaches courses in ethics, philosophy of religion, philosophy of sex and gender, metaphysics, and philosophy of education, and publishes primarily in topics in bioethics, as well as critical thinking in ethics. www.nathannobis.com.