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Jonathan Kahn, The Troubling Persistence of Race in Pharmacogenomics, 40 Journal of Law, Medicine & Ethics 873 (Winter 2012) (80 Footnotes)
“The state is not abolished, it withers away”
-Friedrich Engels, Anti-Durhing
“I'm gonna tell you how it's gonna be.”
-Buddy Holly and the Crickets, Not Fade Away
In 1878, Friedrich Engels famously wrote that on the road to realizing the communist utopia, “the state is not abolished, it withers away.” In a similar manner, biomedical researchers telling us that come the promised land of individualized genomic medicine, the need for using race will also “wither away” in the face of scientific progress. Such millennial hopes are, no doubt, sincere, but they enable the continued casual proliferation of racial categories throughout biomedical research, product development, marketing, and clinical practice. My contrasting quotation to frame this article is drawn from the 20th century pioneer of rock and roll, Buddy Holly (né Charles Hardin Holley) whose 1957 hit “Not Fade Away” begins with the line, “I'm gonna tell you how it's gonna be” --the point being that far from withering away, race is persisting even as genomic milestones are being reached and passed. In short, despite biomedicine's promises to the contrary, race will “not fade away” of its own accord even as the science of genetics progresses.
This article is concerned about what may be happening to race and medicine in the “meantime” between today's clinical realities and the promised land of pharmacogenomics. It argues that previous debates over the use of race in medicine are being side-stepped as race is being reconfigured from a “crude surrogate” for genetic variation into a purportedly viable placeholder for variable drug response--to be used here and now until the specific genetic underpinnings of drug response are more fully understood. Embracing the trope of “promise” in pharmacogenomics alongside the idea of using race as a useful interim proxy for genetic variation raises concerns that new diagnostic and therapeutic interventions may reflect or be mapped upon existing social categories of race, class, gender, and ethnicity in a harmful or dangerous manner. At the most basic level, the politics of the meantime in pharmacogenomics may be promoting what sociologist Troy Duster has termed, the ““molecular reinscription of race”--the scientifically unjustified and socially dangerous recasting of race as a social and historical construct into a reified genetic category.
As race gains renewed legitimacy as an interim measure on the road to individualized medicine, a curious thing is happening: race is persisting even as genetic milestones are reached and passed. This article begins with a brief general examination of how race is persisting in biomedical research with particular consideration of how the concept of the “unknown” is used to create a space for race as a genetic construct. After marking the power of the concept of race as a “stepping stone” in biomedical research, it moves on to explore the case of the widely prescribed blood-thinning drug warfarin (marketed by Bristol-Meyers Squib under the trade name Coumadin®), which involves the persistence of race even as specific genetic variations directly tied to warfarin response are being identified.
I argue here that race is persisting for two additional reasons. First, race is evolving into a “residual category” that is being used to explain any variation in drug response that is not captured by genetics. The irony here is that genetics will never explain 100% of variable drug response. Many complex environmental, dietary, and behavioral factors also affect drug response. In short, an unknown aspect to drug response will always exist; therefore, a potential use for race will always exist as a category to catch this residuum of unexplained variation. Second, there is an inertial force to race in biomedicine. Once introduced into a conceptual system for evaluating biological differences, it is very difficult to dislodge race. It becomes part of the common sense of biomedical practice and continues to be used almost reflexively--not least because the array of federal mandates require biomedical research to gather and classify data by race.