V. Final Thoughts and Future Challenges
Affirmative action remains a controversial and inconsistently effective solution to a complex problem in higher education. Professor Charles Lawrence, for example, has argued that diversity as a justification for [p719] affirmative action fails to remedy deeper societal discrimination and, instead, preserves the current flawed university admissions process. By relying on the diversity rationale as a justification for affirmative action, Lawrence argues that defenders of diversity such as Bowen and Bok “defend the integration of an existing elite without questioning that elite's participation in the reproduction of institutional racism.” The debate about the merits of the diversity rationale coupled with the rapidly developing literature on “race-neutral” preferences receives fuller treatment elsewhere, but medical schools should take whatever steps necessary and consistent with current law to achieve diversity of race, religion, and socioeconomic background in their student bodies.
This Article does not attempt to summarize and discuss the entire debate about affirmative action in higher education. Instead, it considers the practice of race conscious admissions practices as permitted after the Grutter decision and examines the special merits of the practice in medical school education. The Grutter decision affirming racial diversity in the classroom as a compelling governmental interest represents an important first step in the process of eliminating bias in health care delivery. The commitment to diversity can and should remain steadfast in all higher educational contexts, but the conversation about the value and purpose of affirmative action will prove more productive if it is context-specific. Although a diverse class undoubtedly enhances the learning experience for students in undergraduate programs, law, and business schools, the stakes are simply different in medical education. The trickle down effect of under-representation of racial minorities in health care delivery has a far greater impact on society than similar under-representation in law services or business enterprises. It would be indefensible to return to essentially de facto segregated medical education in this era of rapid minority population growth in the United States and continued health disparities between whites and racial minorities. Medical schools must remain committed to social justice as a key component of the ethic of professionalism that students develop during their training.
The United States government has acknowledged the vexing and [p720] seemingly intractable problem of health disparities between the races. Although inadequate access to care contributes to much of these health disparities, the dearth of minority physicians in general and the larger problem of inadequate training to improve the ability of physicians to communicate with patients of different racial or ethnic backgrounds makes progress difficult to achieve. Minority physicians remain more likely than white physicians to treat minority patients, and minority patients continue to express a preference for physicians of the same or similar racial background. Ideally, the medical education system will train all physicians to provide high quality care, with respect and compassion, to all patients, regardless of the race of the physician or patient. Proponents of integrated medical education clearly have made significant strides in the last quarter century, but the continued evidence of racial disparities in health care delivery, racial bias and communication problems between physicians and patients demands an ongoing commitment to the inclusion of substantial numbers of underrepresented minority students in medical school.
Many challenges remain. Continued efforts at diversification of medical school classes and cultural competence training represent only the first step in transforming the health care delivery system in ways that will improve the overall health of Americans and particularly of racial and ethnic minorities. Although it is clear that communication issues and unconscious bias negatively affect the quality of care that minority patients receive in a variety of circumstances, recent evidence suggests that interpersonal discrimination is only one piece of a larger puzzle. The lasting effects of societal discrimination and residual segregation also appear to impact the quality of care that minority patients receive. Moreover, although the evidence suggests that training more URM physicians will actually improve quality of care for URM patients, and that non-minority physicians will benefit from education in a racially diverse setting, it will be difficult to measure directly the actual impact of such reforms on quality of care.
[p721] Ultimately, high quality medical care happens in an environment that encourages meaningful one-on-one interactions between individual health care providers and individual patients. This goal-truly meaningful communication, genuine respect, trust and mutual understanding between patient and physician-if achieved, ultimately can transcend matters of race and culture. An important step toward this goal begins with medical education that trains physicians not only in the science and art of medicine but also in the more universal and essential art of communication. In a society that continues to struggle with matters of race, and in a health care system that continues to deliver health care that is infected with bias, racial diversity in medical education remains an essential tool to train all new physicians to bridge the divide with patients who are different than themselves. Overall, progress is evident and it is heartening. In the past couple of decades, health quality research has moved from recognizing the deeply troubling evidence of racial disparities, to acknowledging that such disparities present challenging ethical and legal dilemmas, to attempting to understand the causes of these disparities and, ultimately, to devising strategies to address them. This final step will undoubtedly prove most challenging. At the very least, graduating classes of new physicians who are aware of and attentive to these issues represents an essential step along the path to equality in health care.
Associate Professor, Western New England College School of Law; J.D. Harvard Law School.
