 Hi there. Welcome back to History and Philosophy of Science and Medicine. I'm Matt Brown. Today we're talking about race and medicine. The primary question for our discussion today is, should race be used as a variable in biomedical research? The background of this question, you know, is something that you probably already know about. There are major health disparities by race, not just in terms of broad outcomes of mortality, morbidity, and general health, but on specific diseases there are different outcomes differentiated by race, and this causes a lot of folks to want to think about what is the role of race in health and how can we study it? You should think about this question, should race be used as a variable in biomedical research as having two sides to it, right? One is an ethical side, right? Is it ethically right, or permissible at least, to use race in that way as a variable, as a thing that we track and measure? And also an epistemological aspect to this, right? Is it something that leads biomedical research to better knowledge, or is it something that leads it astray? And as, you know, you might expect, given some of our previous discussions, that's not really a sharp dichotomy, the ethical and the epistemic aspects of this question mix, and you really need to think about both and the way they relate to one another to come to an answer to the question, right? If you answer yes to the question, yes, race should be used as a variable in biomedical research. The position is sometimes what's called conservationism, right? That is, we conserve the notion of race, right? Or the concept of race within our research context. If you answer no to the question, then you are, then that position is known as eliminativism. And basically, it means, you know, we want to eliminate the concept of race from biomedical research. So those are the positions. There are obviously nuances within and between the positions. And we'll get into some of that here in this lecture and some of it in our discussion today. Let's start with the question, what is race? What is this concept of race? Obviously, to some extent, it's a value laden concept, right? So as we talked about last week with with thick concepts and mixed claims, the concept of race with all of its historical baggage of racism and white supremacy, as the history sort of behind it, and all of the positive and negative sort of roles that race plays in our politics and our society, you're not going to escape thinking about the value ladenness of the term, right? At least, not not and have an adequate conception. A lot of our thinking about race follows just a conventional definition, like what you see in the census, and what's defined by the OMB, the Office of Management and Budget in the United States government, it gives a number of categories, right? Five categories. They are American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander and white, right? Now obviously, these categories are very US centric, right? They're somewhat focused on how we describe different groups within the United States. They also roughly correspond with continental populations, right? So American Indian or Alaska Native is sort of indigenous Americans, North and maybe South America, Asian obviously comes from Asia, Black or African American, we're referring to the descendants of African continental populations, Native Hawaiian Pacific Islander, and then white, presumably, we're looking at European historical populations. But that said, I mean, those don't perfectly line up with historical and geographic anthropological history. So it's just a convention, right? And in the guidelines, they in fact say this is partly just a social convention, right? Another historically important concept of race is what we might call racial naturalism or racialism or essentialism. And this is, you know, this is the discredited historical concept of race in which there are these major biologically grounded differences between different races. This concept I think fails for a number of reasons. One of them is if you look at the genetics, it's what's referred to in the article as LeWanton's argument, right? If you look within a population, a racial group, that population has a great amount of genetic variation. If you look across racial groups at the whole range of differences, there's not much differences from one group to another. Obviously, there are some differences, but they're relatively minor and superficial. Another view of what race is is just the idea that race is a biological fiction. It's a social construction, right? It doesn't really exist, except as a social category, right? There are certain kinds of, there are certain ways in which we categorize people based on superficial characteristics and history, but ultimately, there's nothing, there's no biological reality there. And then finally, another view that's discussed, and to some extent just to defend it in Andreessen's article is the biosocial view, which says it's a mix of some genetic biological factors and some social factors that make up race, right? And often, those who subscribe to the biosocial view will use more modern, more recent genetic techniques to argue that there are actually clusters of genetic correlations that you can kind of associate with racial groups in order to pick out populations that actually aren't that different from the OMB conventional populations. Although, of course, that's to some extent controversial. And one thing I think it's important to note is, although it's important to think about what we mean by race, what race is in thinking about whether we should use it as a variable in biomedicine, views of race don't perfectly map onto the question, right? So, whether you're a social constructivist, a biosocial view person, or even if you subscribe to racialism, it doesn't necessarily mean that we should or shouldn't, it doesn't necessarily prescribe a view about whether we should use race as a variable in biomedical research, because, you know, race may be real, it may exist, right? But not have any significant information, you know, may not be informative for the causes of disease. That's a possibility, right? Similarly, race could be totally a social construction, totally a biological fiction, and yet there would be reasons you want to keep track of it in biomedical research. So, really, we need to think about, to some extent, how race is measured and then largely how the race might be used to keep track of important information in biological research and what problems might arise if we use it in that way in order to raise the pros and cons of eliminativism and conservationism. So, against the notion of using race in medical research, one of the major arguments is simply that the use of race in research tends to reify race, tends to support the racial naturalist position that certain, you know, parts of our society are just already predisposed to believe, right? So, insofar as, you know, we are tracking race and correlating race and we are reporting, you know, racial differences and susceptibility to diseases like diabetes or sickle cell anemia, it tends to make race seem more real, right? And that actually can mislead or be harmful. Another idea against is that measuring race itself is somewhat unreliable, right? So, we've, I gave you sort of the categories of race that are used for federal purposes a moment ago, but those don't come with any criteria that specify how you determine which race someone is. In fact, the only thing that you really have is self-identification, right? What race does the person you're, you know, asking identify with, right? One of the nice things about the relatively newer way of doing this is that, number one, it is self-identification rather than other identification, right? Which can be more problematic, right? So, it's not up to the scientist to assign a race to you based on whatever they are basing it on. It's up to you as the person being measured to specify. And also, you can check more than one box, so to speak, right? So, it does naturally accommodate mixed-race identified people. But that said, the reasons that person A might identify as, say, Asian, and person B might identify as Asian may not be the same, right? Someone may focus on their ancestry, another person may focus on their appearance, right? And those things don't generate the same answer. So, there may be some unreliability in the measurement. Although, there are arguments that it's not as bad as it might sound, right? That actually, it tracks fairly well. Another argument is that race gets confounded with a bunch of other factors that might be more directly influential on health outcomes and disease etiology, right? So, an obvious one is racism, right? If you are a member of a certain racial group, you're more likely to or you're inevitably going to experience some racism. And that might have negative health outcomes, right, on its own. But you can't really pull apart very reliably those two variables. There tends to be a kind of suite of socioeconomic and environmental factors also that you can sometimes, but not always, pull apart. A related concern that many researchers have is that really, when it comes to understanding the causes of disease and of health, individual context, the context of an individual subject or patient is always going to be more useful than gross generalizations about racial groups that are, you know, internally diverse groups of people. And so, it's kind of unnecessary and the focus leads us away from what we need to focus on, which is more individual context. One problem with that notion is that individual context is actually quite hard to study, right? We tend to, as a matter of methodological necessity, focus on groups of people whose characteristics we can specify and broad generalizations about the groups. You know, we also include information about the variants across the group, right? But it's really hard in a context where you focus on these large medical trials as your main form of evidence to say much that's interesting about individual context. So that's a difficulty. Those who are for the use of the variable of race and medicine have a variety of different reasons. And in fact, they may disagree with one another in part based on, you know, some are, have a totally social concept of race. Others have more of the biosocial concept of race. And those groups are sometimes going to have different notions of why we might still want to keep track of race. So, you know, one very prominent view is that, you know, racial disparities are real, right? Racial disparities and health outcomes are real. They're typically unjust, right? And you need to be able to track them if you want to fight that injustice, right? If you want to, if you want to deal with that injustice, you have to actually know what the disparities are. So you have to keep measuring them, right? That even if you don't think race is biologically real, that's a good reason to think about why you should keep track of race and biomedical research. Another aspect, another view, which is more on the biosocial side of things is that, you know, some diseases have fairly clear genetic origins, genetic etiology or genetic associations, right? So diseases like Tay-Sachs disease, diseases like sickle cell anemia, and a variety of others have fairly simple genetic explanations. And those, those sort of the genetic factors might differ in prevalence between racial groups. And in fact, there's evidence for some of these that there is a sort of difference in prevalence between racial groups. So because race is related in the, especially in the minds of those with the biosocial view, with these sort of ancestral populations that are reproductively isolated from one another, and so have some genetic differences, this could be relevant. Others have disputed whether there are really significant genetic differences along these lines. Obviously, it's an empirical question. And, you know, one argument in favor of continuing to measure race is that it leaves open the possibility, right, to discovery, right? The last sort of notion of why we might want to measure race in biomedical research is that race could be a useful surrogate variable, even if it is not a sort of a biological reality, and even if it's not perfectly correlated, correlated with the underlying factors that do cause disease. And this I think goes to the notion of, of, of value laden concepts or mixed claims, right, because racial groupings are our social groupings that we care about, we care about them, because often we politically identify with a racial group, especially members of marginalized racial groups have solidarity with each other. We have a history of racism and white supremacy in the United States and globally that has generated a variety of racial injustices. And so insofar as racial groupings stand in for a whole suite of intersecting factors having to do with social discrimination, socioeconomic status, geographical distribution, you know, we still have housing discrimination in a lot of cities in the United States. So, so, so different racial populations live in different places, environmental factors, including environmental racism, all of these things intersect in ways that cause disease profiles that are unique. And these are things we care about because we care about race, if only to fight racial injustice, right? So it's not just that we want to, you know, track the disparities because we want to fight them, but also we're interested in how this sort of suite of factors that tracks a concept that we care about is affecting people's health, right? And how it, you know, in some sense, this sort of shifts our notion of what the fundamental or most important causes are from a purely sort of biological understanding of what the disease factors are to a socially focused notion of what the important factors are. And that's a different way of sort of cutting up the causal space that actually might be more useful to us. Okay, so that's a kind of detailed, but I hope helpful introduction to this topic. You know, ultimately the question, we have to try to integrate all these different considerations, all the ethical and epistemic considerations that are raised and the intersection between them, in order to try to answer this question. So that's the introduction to race and medicine. I look forward to talking about this with you more on Discord or in our class meeting today, or I'd be happy to answer questions in the comments of the video and hear your thoughts. This is our last topic for this semester's discussion. It's been a pleasure speaking with you. And I want to wish you luck on your exams and have a great summer. I'll see you in class or I'll see you sometime in the future. Bye.