I. Introduction

Many people are surprised at the level of distrust of the health care system held by African Americans. However, fear and distrust of the health care system is a natural and logical response to the history of experimentation and abuse. The fear and distrust shape our lives and, consequently, our perspectives. That perspective keeps African Americans from getting health care treatment, from participating in medical research, from signing living wills, and from donating organs. That perspective affects the health care that African Americans receive. This fear and distrust is rarely acknowledged in traditional bioethical discourse.

Some bioethicists question the existence of a uniquely African American bioethical perspective. They maintain that since the values and beliefs held by African Americans are also held by other oppressed groups, such as Native Americans, there is no African American perspective. However, these traditional bioethicists miss (or ignore) an important point: perspective is merely a subjective evaluation of the relative significance of something--a point-of-view. Thus, to acknowledge an African American perspective, it is not necessary that African American values and belief systems be entirely different from others.

It is faulty to assume that any group shares exactly the same value system with other groups. For example, Americans do not have one ethical perspective. Rather, race, class, and gender modify the commonality of the American experience. Different groups have had different experiences that, at a minimum, modify the dominant American perspective, if not replace it with an entirely different value structure. For African Americans, the combination of slavery, segregation, and racism have given us a different set of intervening background assumptions about such essential bioethical concepts as personhood, bodily integrity, the moral community, fulfilling lives and utility.

As a subculture of the American society, we have experienced something that others have not. The unique combination of slavery, segregation, and racism have caused us to develop not only different behavioral patterns, values, and beliefs but also different definitions, standards, or ordering of values. Furthermore, even where there is little difference in value systems and perspectives, there is a difference in the normative application of bioethical principles. For instance, there is no question that the principles of autonomy, beneficence, nonmaleficence, and justice have not been applied to African Americans in the same manner as European Americans.

In the Poplar Tree Narrative Dr. Dick, a conscientious physician, applies the prima facie principles of beneficence, autonomy, and justice in such a way that castration of his black male patient is construed as a morally justifiable act, in substance and as a procedure . . . . [It kept the male] from getting into trouble . . . . [It made the male] . . . a better slave. . . . [He protected the male patient's autonomy] by getting what he construes to be [the patient's] informed consent.

The apparent principles of Eurocentric bioethics are embedded in a cultural matrix that encodes them with meaning. The reality of bioethics is that ideas, such as autonomy, choice, beneficence, justice, and informed *194 consent, are grounded in perspective and cultural context. Perspectives are based, in part, on class, race, and gender experiences. The experiences of poor people are different from those of rich people; those of African Americans are different from European Americans, Native Americans, Hispanic Americans or Asian Americans. Experiences differ for women and men. Furthermore, rich people, White people, and men have more power than poor people, African Americans, or women. Power also affects experiences. A group's perspective reflects both cultural context and power or status differentials.

But what then forms the basis of the African American perspective? Certainly, African American culture has acquired a significant part of its roots from the continent of Africa. For us, that means a belief system that includes a humanistic orientation, a focus on both personal and social responsibilities, and a high value placed on community belonging. To the extent that bioethical discourse and practice do not incorporate these values, they do not reflect the values of the African American community.

However, African Americans' distrust of the health care system is based on more than a lack of certain African-based values. Our distrust is the direct result of our unique cultural birth in America. The African American culture is uniquely American. In some ways, African Americans, like Indians and *195 Eskimos, are native Americans; that is, as a culture, African Americans exist only in America. African Americans are a blend of all the races of the world. The dominant racial basis for our group is a blend of features from many African tribes. The most prominent influence on African American culture has been its past (and present) experiences of slavery, segregation, and racism. These African American experiences are clear evidence of cultural context, power, and status differentials which have resulted in a distrust of the health care system. This historical distrust is reinforced through current, continued, and ever-present institutional racism. These experiences fuel the basis for African American distrust.