Just Medicine: A Cure for Racial Inequality in American Health Care

Just Medicine: A Cure for Racial Inequality in American Healthcare is a pioneering work written by Dayna Bowen Matthew, a legal scholar specializing in public health who draws on her extensive background in civil rights law and health policy to demonstrate the pervasiveness of racial disparities in the US healthcare system. Originally published in 2015, this book provides an in-depth analysis of how implicit bias, institutionalized discrimination, and structural inequalities shape health outcomes for marginalized racial and ethnic groups in the US.

Dayna Bowen Matthew is a professor and Dean of Law at the George Washington University Law School. She is also Harold H. Greene Professor of Law at the same university. Her academic expertise and public advocacy work are central to Just Medicine, as she draws on abundant evidence from medical studies, social studies, law expertise, interviews with people in a wide range of professions related to healthcare, and personal experience to make an argument for a systemic change in healthcare. Matthew’s writing is scholarly, yet accessible to a wide public and policymakers alike.

Just Medicine is a non-fiction book, with a specific focus on health law, public health policy, and social justice. The work engages with current and historical topics of healthcare reform, civil rights, and the role of law in dismantling systemic inequalities. Dayna Bowen Matthew has spoken at numerous academic and public institution venues presenting her research and proposed solutions in Just Medicine.

This guide focuses on the themes of The Role of Implicit Bias in Healthcare Disparities, The Systemic Challenge in Addressing Implicit Bias, and The Importance of Legal Reforms that Address Implicit Bias. This guide references the 2015 New York University Press paperback edition of Matthew’s book.

Content Warning: The source text and this guide discuss racism—both overt and implicit. The source text also utilizes the terms minority and minorities to refer to non-white individuals and communities.

Summary

In the Introduction to Just Medicine, Dayna Bowen Matthew highlights the persistent racial and ethnic disparities in the US healthcare system. She argues that racially marginalized patients receive inferior care compared to white patients, leading to significant health inequities. While socioeconomic factors contribute to these disparities, Matthew emphasizes that implicit racial biases—unconscious prejudices held by healthcare providers—are a major cause. These biases impact decision-making and perpetuate inequality. Matthew calls for systemic solutions, noting that existing antidiscrimination laws are inadequate as they focus only on explicit racism rather than implicit biases.

In Chapter 1, Matthew argues that racism is a root cause of health disparities in the US and that legal systems have historically reinforced this inequality. She traces this argument back to colonial laws that equated BIPOC individuals to property and allowed the seizure of Native American lands and the dehumanization of enslaved Africans. In the 19th century, laws promoted segregation and denied immigrants and BIPOC populations access to healthcare, leading to unsanitary living conditions. Even though civil rights victories challenged healthcare segregation, the effectiveness of these legal protections decreased by the late 20th century. The courts began rejecting challenges to more subtle forms of discrimination, significantly weakening laws like Title VI. Matthew concludes that legal structures have historically contributed to racial health disparities, which persist today, and calls for legal reforms to address unconscious discrimination in healthcare.

In Chapter 2, Matthew attributes persistent racial and ethnic health disparities to implicit biases among physicians, rather than overt racism. Through interviews, she finds that many doctors are unaware of their biases, unconsciously relying on stereotypes when diagnosing and treating patients. Matthew explains that implicit biases form from a lifetime of social exposure and automatically influence behavior, despite doctors' intentions to provide equitable care. She discusses tools like the Implicit Association Test (IAT), which measure these unconscious biases and reveal a prevalence of pro-white and anti-Black attitudes, even among healthcare professionals. These biases shape doctor-patient interactions, leading to unequal care. Matthew highlights that patients also hold implicit biases, which affect their relationships with doctors.

Chapter 3 explores how unconscious racism in healthcare harms BIPOC patients and increases costs. Implicit bias leads to disparities, such as withholding specialist referrals for BIPOC patients, despite laws prohibiting intentional discrimination. The 2003 Institute of Medicine report revealed that marginalized groups receive inferior care for conditions like heart disease, cancer, and diabetes, even when controlling for socioeconomic factors. Studies demonstrate that physicians, influenced by unconscious bias, offer fewer preventive and specialized treatments to BIPOC patients compared to white patients. Matthew also presents a study by Dr. Irene Blair, which suggests that strong patient-doctor relationships can reduce the impact of bias in some cases, highlighting the need for further study.

In Chapter 4, Matthew introduces the Biased Care Model, which identifies six mechanisms linking physician and patient bias to unequal health outcomes. The model addresses how systemic pressures, cognitive overload, and uncertainty in healthcare exacerbate implicit bias, influencing interactions before, during, and after clinical encounters. These biases result in different care standards, such as withholding referrals or misinterpreting patient symptoms.

In Chapter 5, Matthew discusses how physicians’ implicit racial biases affect their conduct and communication, leading to lower-quality care for BIPOC patients. She explains that these biases manifest in verbal and nonverbal interactions, with doctors often displaying less empathy and spending less time with BIPOC patients. Research shows that white physicians may feel anxiety or hostility towards BIPOC patients, resulting in less patient-centered communication which, in turn, reduces their trust, satisfaction, and health outcomes. She explores how implicit biases create a feedback loop, with both physicians and patients influencing each other’s behaviors.

Chapter 6 discusses how physicians’ implicit biases affect diagnostic and treatment decisions, contributing to health disparities. Despite physicians denying biases, research shows that racial stereotypes influence medical care, such as favoring white heart disease patients for treatments like thrombolysis over Black patients. Implicit biases also affect perceptions of patient adherence, leading to discriminatory treatment recommendations. Matthew explores how patients’ perceptions of bias lead to dissatisfaction, mistrust, and avoidance of healthcare, negatively impacting their adherence and follow-up care.

In Chapter 7, Matthew argues that unconscious racial biases in healthcare are controllable and not inevitable. She presents evidence demonstrating that implicit biases are malleable and can be altered through deliberate efforts, such as correcting bad habits. Matthew outlines three intervention strategies designed to reduce biases at different stages of cognitive processing: prevention of stereotype activation, counter-stereotype building, and leveraging social motivation to inhibit biased behaviors. Matthew argues that the malleability of biases has significant implications for law and policy, and institutions should hold individuals accountable for addressing implicit biases.

In Chapter 8, Matthew advocates for a radical shift in addressing unconscious racism in healthcare, emphasizing systemic change over individual interventions. She critiques current efforts, like education and bias awareness training, for being insufficient in tackling the structural roots of health disparities. Using Thomas Frieden’s Health Impact Pyramid, Matthew argues that addressing socioeconomic determinants, such as housing, education, and employment, will have a greater effect on reducing disparities than individualized solutions.

In Chapter 9, Matthew proposes reforms to Title VI of the Civil Rights Act to combat racial and ethnic health disparities caused by implicit bias. These reforms include prohibiting policies with disparate racial impacts, restoring private litigation rights, and introducing negligence-based claims. Matthew critiques Title VI for focusing only on intentional discrimination, overlooking implicit bias, which leads to unintentional yet harmful disparities. Drawing from employment discrimination law, she advocates for a negligence standard of care to hold organizations accountable for bias-driven outcomes.

In the Conclusion of Just Medicine, Matthew highlights the importance of Section 1557 of the Affordable Care Act, which prohibits healthcare discrimination. While it offers protections, Matthew argues it is incomplete, as regulations and enforcement are still developing. She emphasizes that systemic change is needed beyond legal reform to address racism in healthcare, calling for deeper research and a multi-sectoral approach to tackle the socioeconomic factors driving health disparities.