Are doctors’ offices places for racial profiling?
Are race-based treatments unethical?
Sally Satel, MD, is proud to be a racially profiling doctor.
The practicing psychiatrist and fellow at the Washington, DC-based conservative think tank The American Enterprise Institute says it’s important for clinicians to consider racial and ethnic factors when making diagnostic and treatment decisions for patients.
"Certain diseases and treatment responses cluster by ethnicity," she wrote in the May 5 issue of The New York Times Magazine.1 "Recognizing these patterns can help us diagnose disease more efficiently and prescribe medications more effectively. When it comes to practicing medicine, stereotyping often works."
For example, clinical research and her own personal experience have shown her that African-American patients metabolize antidepressants more slowly than Caucasian and Asian patients do. If this happens, levels of the medication in the body can build over time and lead to side effects, such as insomnia, nausea, and confusion. Therefore, Satel frequently starts her black patients at a lower dose of antidepressants.
Admittedly, not all black people metabolize these medications slowly — only an estimated 40% do. But the likelihood is significant enough that she feels she should take this into consideration, she tells Medical Ethics Advisor. "If you were wrong to start the patient at a lower dose, you can simply raise the dose later."
This is preferable to initiating drug therapy that might cause side effects that may lead an already vulnerable patient to stop taking the medication altogether.
Satel is not alone in her approach. Other doctors agree that they have long considered racial and ethnic background as factors in making decisions based on their experience with certain groups of patients.
Now, clinical studies are beginning to examine how members of different ethnic groups respond to standard treatment regimens and whether these groups may be at higher risk for certain types of diseases.
A report in the May issue of the journal Clinical Infectious Diseases indicates Hispanic immigrants are at higher risk for infections that do not usually occur in the U.S.-born population. A recent study in the journal Hepatology reported on the higher prevalence of gall-bladder disease among American Indians, and a study in the June issue of The American Journal of Clinical Nutrition proposed a need for different body-mass index cutoffs in different racial and ethnic groups.
A pair of particularly controversial studies published in the May 2001 issue of the New England Journal of Medicine highlighted differences in the response to certain heart medications observed between African-American and Caucasian men.
The first study, by Exner and colleagues, found that the drug enalapril was more effective in treating left-ventricular dysfunction in white patients than in black patients.2 Another study in the same issue concluded that the drug carvedilol was equally effective in treating chronic heart disease in both white and black patients.3
But some doctors and researchers are criticizing such studies, claiming that their focus on linking treatment responses and risk factors to specific racial and ethnic groups is misleading and scientifically dangerous.
Genetics, not race, is the key
"You have to bear in mind that, from a biological point of view, the definition of any race is arbitrary," says Robert Schwartz, MD, a deputy editor at the New England Journal of Medicine, who wrote an editorial commenting on the studies of racial differences in response to the heart medicines.
Genetic studies are showing what scientists have long believed — that there are no biologically distinct races of people, he says. Differences in response to treatment or risks for disease differ because of a person’s genetic makeup.
People who are from one area of the world will tend to have similar genes and genetic mutations, he says. But, as world populations have intermingled it has become less likely that specific genetic mutations can be attributed to people of a certain geographic origins.
"If you have an individual patient in your office, how do you know that patient has the gene that affects the metabolism of that drug?" Schwartz asks. "You can only guess. Just saying, Well, the patient is black and, therefore, I am not going to give him a beta-blocker’ is, to me, not the way to practice medicine."
A recent study of the occurrence of genetic polymorphisms (gene mutations linked to specific traits) have found that of the five genes involved in metabolism, race was not an accurate predictor of the occurrence of the polymorphisms that made metabolism slower, he points out.
"The frequency of a polymorphism involving drug metabolism had the same frequency in Ethiopians as it did in Norwegians," he notes. "So that is why, from a biological point of view, we have to be very, very cautious."
The impetus behind many of these new studies is that for very many years, black people and members of other minority populations were not included in clinical research trials. So, information about effective treatments was largely determined by only studying one group of people, Schwartz admits.
But studies that now hope to remedy that situation risk making it worse by focusing on distinctions by racial groups or ethnic factors, which can lead to further stereotyping and stigmatization, he says.
The studies’ real goal is to determine the environmental, cultural, and genetic factors that influence disease and response to treatment, so it would be better if researchers deliberately focused on these areas.
"Right now, we are on the edge of what many people are beginning to refer to as personalized therapy," he says. "You will be able to obtain accurate information on the likelihood of a response or no response from a single drop of blood, through DNA."
It’s true that geographic ancestry and the currently identified racial groups are only rough markers for the genetic traits that may affect a person’s response to treatment, but right now it is the best information available, and physicians would be remiss in ignoring it, argues Satel.
She does not advocate making a decision about a diagnosis or treatment based solely on a person’s race or ethnicity, but says these factors, like so many others considered during a work-up, must be considered.
"Diagnosing is a process of elimination," she explains. "You have to think of the likelihood of what is wrong, and you rule out with tests, typically. If that does not explain the pathology, you go on to the next potential diagnosis. The point is, you will get there eventually even if you do not know the person’s race, but it is just a bit of information that might help you get there quicker."
References
1. Satel S. I am a racially profiling doctor. The New York Times Magazine. May 5, 2002.
2. Exner DV, Dries DL, Domanski MJ, et al. Lesser response to angiostentin-converting enzyme inhibitor therapy in black as compared to white patients with left-ventricular dysfunction. N Engl J Med 2001; 344:1,351-1,357.
3. Yancy CW, Fowler MB, Colucci WS, et al. Race and the response to adrenergic blockade with carvedilol in patients with chronic heart failure. N Engl J Med 2001; 344:3,558-3,565.
Sources
- Robert Schwartz, MD, New England Journal of Medicine, 10 Shattuck St., Boston, MA 02115-6094.
- Sally Satel, MD, American Enterprise Institute, 1150 17th St., N.W., Washington, DC 20036.
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