See Article, page 963

In 1985, the Task Force report from the Department of Health and Human Services on Black and minority health (MH) estimated that 60,000 excess deaths per year occur because of health disparities.1 This was a landmark report and represented the first comprehensive government-funded study of racial and ethnic MH in the United States.2 It was also the impetus for bringing MH into national focus. MH refers to the distinctive health characteristics and attributes of racial and/or ethnic minority groups, as defined by the U.S. Office of Management and Budget (OMB), that can be socially disadvantaged due in part to being subject to potential discriminatory acts.3 A mere 7 journal articles examining racial disparities in medicine were indexed with PubMed in 1985. Since then, national initiatives such as the WHO Commission on the Social Determinants of Health, the MacArthur Foundation Network on Socioeconomic Status and Health, and the Robert Wood Johnson Foundation Commission to Build a Healthier America have spurred increased recognition of inequities in MH outcomes resulting in more than 3400 health disparities journal articles indexed on PubMed in 2021. The documented racial and ethnic disparities, which have at times been erroneously ascribed to biological variations, have prompted debate of the best approach to achieving equity in health care outcomes.4 To this end, color blindness has been presented as a means to eliminate discrimination and racial disparities in health and health care outcomes. Racial disparities have also been identified within anesthesiology.5–9 As anesthesiologists grapple with how best to provide equitable care,10 it is important for physician scientists to address whether or not perioperative research should be color-blind. In this Pro-Con commentary article, we discuss the concept of color blindness and its role in medicine and research (Table).

PRO Color Blindness as a Social Ideology

Color blindness is an ideology that supports the notion that equality is achieved by disregarding individual racial and ethnic characteristics when making decisions of opportunity and resource provision.4 Conceptually, racial color blindness is often referred to in the debate of constitutional law. In 1895, as the only dissenting US Supreme Court Justice in a decision that upheld the constitutionality of racial segregation, John Marshall Harlan argued that “our Constitution is color-blind, and neither knows nor tolerates classes among citizens.”11,12 Harlan’s sentiments are some of the earliest known references to color-blind ideologies.

Table. - Pro-Con Debate Summary PRO: arguments in favor of the color-blind approach to medicine and research  Racial categorization in medicine perpetuates inequities in health care. For example, incorporating race into eGFR calculation has led to listing Black patients for renal transplant later in their disease progression than White patients.  Race-based clinical guidelines do not apply to the increasingly multiracial patient population.  Racializing diseases may lead to misdiagnosis. For instance, viewing sickle cell disease as a “Black” condition has delayed diagnosis and care to patients who do not fit the racial mold.  Emphasizing race in perioperative care and research may detract from the underlying source of inequities: systemic discrimination and the social determinants of health. CON: arguments opposed to the color-blind approach to medicine and research  Color blindness justifies inattention to minority health.  Color blindness emphasizes the “sameness” of patients and, by doing so, ignores the individual’s racialized experience (color evasion).  Color blindness fails to acknowledge the role of institutional racism in an individual’s life (power evasion). In contrast to color blindness, color consciousness incorporates individuals' race and their experiences as fundamental to their health.  Color conscious research and clinical care encourage researchers and policymakers to include the views and experiences of people of color.

Abbreviation: eGFR, estimated glomerular filtration rate.

Color blindness as an approach to alleviate race-based social injustices gained support during the Civil Rights Movement. In the 1960s, color blindness signified the goal of justice in race relations, and those supporting color-blind ideologies generally did so in hopes of alleviating discrimination.12 However, antiracist adversaries of color blindness soon recognized a widening gap in socioeconomic deprivation between White and Black citizens. They argued that by ignoring the social context of race, color blindness ignores the structural factors that perpetuate systemic discrimination and racism.13 They defend, instead, that race consciousness aims to address racial discrimination by responding to the structural barriers that have long impeded full social, political, and economic participation to people of color.14 However, antagonism to color blindness because of the belief that race-neutral ideologies minimize the role of race in societal inequities is misconstrued. Evolved from color blindness of centuries past, modern color-blind ideologies do not ignore the existence of social disadvantage and discrimination, but rather strive to focus efforts beyond skin color in the pursuit of an equitable and just society.

Color Blindness in Medicine

Race is not a biologic category. It is not a group of genotypes with historical geographic origins. Race refers rather to physical differences that groups consider socially significant: race is a social construct.15 The phenotypic differences used to sort people into racial categories, such as skin color, may have ancestral roots in our genome, but the pattern-based concept that uses those differences to draw conclusions about broad groups of individuals serves only to establish a deleterious and hierarchical organization of humans.16

The use of race in medicine is problematic and may even serve to perpetuate inequities in health care. The calculation of estimated glomerular filtration rate (eGFR) when assessing renal function serves as an example. The eGFR formula, until recently, was based on age, gender, level of creatinine, and race (Black or non-Black).17 This eGFR formula assumed that Black people have higher muscle mass on average, a theory which has been debunked. The inclusion of race in the eGFR calculation resulted in Black patients with renal failure being placed on transplant lists later than their White counterparts. At one institution, the removal of the race coefficient from the eGFR equation increased transplant eligibility for Black patients.18 The National Kidney Foundation and the American Society of Nephrology has since recommended immediate and widespread adoption of an eGFR formula that does not differentiate by race.

Clinical applications of race assume that racial categories are well-defined and universally applicable. Take for instance, medical guidelines with alternate recommendations for patients of differing race. In 2018, the multisociety Guideline on the Management of Blood Cholesterol was released, using race/ethnicity to determine the presence of “risk-enhancing factors.”19 In this version, the guideline highlights increased sensitivity to statins in East Asians and the importance of managing hypertension in Blacks/African Americans. Race-based guidelines such as these leave large groups of people without an identity. Those individuals who do not fit perfectly into a racial/ethnic category go unrepresented. In 2013, the proportion of multiracial newborns was 10%, an increase from 1% in 1970.20 In this American society of increasing admixture, clinicians are unable to effectively manage patients of blended racial background when presented with treatment recommendations for specifically defined subsets of the population.

Racializing disease in medicine risks harming not only the minority patient, but patients of all backgrounds. For example, the classic teaching in medical schools is that sickle cell anemia is a “Black” disease.21 However, patients have been misdiagnosed when showing symptoms of these diseases because they have not fit the “racial mold.” Although the majority of Americans with sickle cell disease are Black, 1 in every 16,300 Hispanic-Americans is affected, and 3 of every 1000 White births and 2.2 of every 1000 Asian and Pacific Islander births have sickle cell trait.22 When we fail to be color-blind in our application of medical knowledge, we can inadvertently and unintentionally harm our patients, violating the ultimate tenant of our profession: primum non nocere.

Race in Perioperative Research and Care

Enhanced Recovery After Surgery (ERAS) protocols in perioperative care have a demonstrated track-record of decreasing surgical outcome disparities. By using standardized perioperative medication regimens, particularly with regard to analgesics, and preoperative and postoperative care optimization practices, ERAS protocols avoid giving undue, and possibly biased, consideration to patient factors such as race or ethnicity. ERAS protocols were designed to decrease hospital length of stay and hospital costs, but by treating patients of specific surgical populations equally, ERAS protocols have narrowed the racial gap in some surgical outcome measures. The implementation of ERAS in a colorectal surgery program decreased the hospital length of stay for Blacks, ultimately leading to similar postoperative hospital recovery time across races.23 Likewise, Black women previously had higher postoperative pain scores than White women following cesarean delivery. The application of an ERAS protocol improved pain scores for Black patients such that the postoperative pain experience is now equitable in the cesarean delivery population.24 Standardized protocols, such as ERAS, are effective at reducing racial disparities in perioperative outcomes because they effectively remove implicit biases from the treatment equation. Implicit biases are the “attitudes [and] stereotypes that impact understanding, actions, and decisions in an unconscious manner.”25 It is well established that most health care providers have implicit biases that are preferable to White patients over Black patients.26 Under conditions of stress and mental fatigue, treatment decisions are susceptible to the influence of these implicit biases, which makes the reliance on standardized care approaches all the more essential to providing equitable anesthetic care.

In perioperative medicine, racial disparities in treatment provision and outcomes have been documented in nearly every surgical specialty and quality metric.27–31 Minority patients have greater disease burden, more frequent surgical complications, longer hospital stays, greater hospital costs, and higher mortality rates than White patients. However, by overracializing perioperative disparities, we may be doing a disservice to minority patients. Placing excessive emphasis on race as the exclusive source of disparity distracts from the most probable and proximate underlying causes: the social determinants of health. Several risk factors have emerged as potential explanations for the described inequities in surgery. Lack of affordable and comprehensive insurance, poor access to high quality and timely care, lesser opportunities to receive advanced surgical techniques, inadequate care coordination, language barriers, and lower levels of health literacy are some examples. It is becoming clear that it is not the color of the skin that directly determines perioperative outcomes—the proximal causes of health care disparities are heavily influenced by the social determinants of health and structural racism, which, unfortunately, are not color-blind. Yet, perioperative research on these subjects is sparse. Now it is time to understand the mediators of surgical inequities and determine effective interventions to mitigate disparities, which can only be accomplished by shifting the focus from taxonomic categories, such as race, to social relations. Perioperative care and research that is centered on race is not going to eliminate disparities. Instead, race-neutral perioperative care and research that is used to help guarantee delivery of consistent and inclusive care of the highest quality to all patients is not only prudent, but morally essential.

CON

Color blindness in clinical care and in research is oversimplistic and deleterious. While Color-Blind Racial Theory (CBRT) was born as a racial ideology from its use in constitutional arguments, it has since permeated academia. By reducing and simplifying arguments from the Civil Rights Movement, CBRT justifies inattention to the health of racial and ethnic minorities in the United States. Dr Martin Luther King Jr’s own words about his desire that his children should “not be judged by the color of their skin but by the content of their character” have been misrepresented and utilized to justify color-blindness arguments.12 Indeed, while color-blind views started as early as the late 1890s, CBRT became stronger in response to the Civil Rights Movement and the passage of the voting rights act in 1965. Color blindness became a means to counteract affirmative action and welfare rights and neutralize the antiracist movement of the 1960s.

Color Blindness, Color Evasion, and Power Evasion

Color blindness portrays itself as antidiscriminatory by supporting equal treatment and opportunities for all individuals. However, the fundamental doctrines of CBRT contradict its apparent unbiased nature.32 Color-blind ideologies encompass two principles: color evasion and power evasion. Sociologist R. Frankenberg explained how these two dimensions, which are closely interrelated, are inherently racist: Color evasion emphasizes the similarity of individuals of various backgrounds as the basis for rejecting sentiments of White superiority. But in doing so, color evasion denies a person of color his own race and more importantly, invalidates his racialized experience. Power evasion, on the other hand, posits that every individual has the same opportunities and, therefore, failure to succeed is the fault of the people of color themselves. However, power evasion fails to acknowledge the role of institutional racism in an individual’s life. Modern power evasion claims that racism is a figment from the past and denies that systemic racist practices hamper growth for some populations while privileging others. Indeed, according to prominent scholar Ibram X. Kendi, if you “truly believe that racial groups are equal, then you also believe that racial disparities must be the result of racial discrimination.”33 Therefore, the very essence of race-neutrality and its assumption of an equitable society denies historical trauma and the cumulative effect of racism on health and health disparities of individuals and population groups.

Clinical research and its “objectivism” have implicitly endorsed CBRT approaches. The oversimplification and lack of attention to determinants of health, including racism, are examples of this. Some studies just simply ignore race and ethnicity, grouping all individuals together for analytical purposes, while other studies include race and ethnicity but over emphasize individual and interpersonal mechanisms of health and health outcomes. Ignoring individual race and ethnicity is an illustration of color evasion. Explaining differences in health and health outcomes primarily by personal characteristics denies structural racist factors and is an example of power evasion.

Critical Race Theory and Public Health Critical Race Framework

Critical race theory provides a framework that incorporates racism as an inherent part of an individual’s experience and therefore as a factor in health research. Public health researchers have embraced critical race theory views and combined them with social justice principles to develop a Public Health Critical Race Framework.34 This framework has 4 principles that directly oppose the color evasion and power evasion notions of CBRT. The first of these principles is race consciousness, which explicitly calls for the understanding of racialized constructs and mechanisms and their effects on the health and health outcomes of individuals. This principle opposes color evasion by viewing individuals’ race and their experiences as fundamental to their health. The second principle of the Public Health Critical Race Framework is contemporary orientation, which holds that structural racism is contextual and evolves over time. This principle opposes power evasion principles by identifying structural racism as a cause of inequality. The third principle is centering in the margins, which directly calls for research and policy that is centered on individuals that belong to marginalized groups. This principle forces research and policy to deviate from the “majority” to include the views and experiences of those who are at the margins of society. The last principle is praxis, which intentionally emphasizes the need to apply critical race theory to the practice of research; for example, using community-based participatory research to explicitly highlight the voices of the community, or research participants who belong to these communities.

Race Consciousness and Perioperative Care

Standardized care (including ERAS protocols) may be a promising approach to reducing the racial gap in perioperative care. Indeed, ERAS protocols have been shown to reduce disparities for some surgical outcomes. However, standardization does not equate to color blindness. Without considering the needs of particular populations, standardization can result in increased disparity if a color-blind intervention has less effect for one of the patient groups.35 A case-matched study of perioperative and pain-related outcomes in a head and neck oncology population investigated the effects of ERAS implementation on decreasing postoperative opioid use. Although protocolized multimodal pain management produced an overall decrease in opioid requirements through the third postoperative day, Black patients did not show the same response. In multivariate analyses, race was an independent risk factor for higher postoperative opioid usage.36 Similarly, in a study of ERAS protocol use for patients undergoing open gynecologic surgery,37 reductions in opioid use after preemptive multimodal analgesia were lower among Hispanic and African American women. These studies illustrate how, by using color-blind approaches that treat patients equally rather than equitably, we fail to account for individual and population-based factors that influence health. Studies are needed to understand factors underlying the differential responses between populations so that quality improvement approaches can be tailored to minority patients.

Alternatively, race-conscious clinical care initiatives are demonstrated by the work of the Society for Obstetric Anesthesia & Perinatology (SOAP). SOAP directly acknowledges the role of race and racism in patient care and outcomes disparities. As a result, the organization has made specific recommendations for anesthesiologists and hospital systems aimed at documenting and mitigating inequities in maternal and perinatal health.38 These recommendations include universal documentation of race, ethnicity, and primary language in the electronic medical record, defining important process and outcomes measures and stratifying those by race and language, creating a disparities dashboard, engaging vulnerable patient populations in multidisciplinary outreach efforts, and supporting workforce diversity. SOAP’s focus on at-risk populations exemplifies the centering in the margins approach to race-conscious equitable care.

Race Consciousness and Clinical Research

Methodologically, color blindness is a problematic approach to research. By grouping individuals of all races and ethnicities into a single category for analysis, researchers lose their ability to understand population differences and introduce confounding. For this reason, national agencies, such as the Centers for Disease Control and Prevention and the National Center for Health Statistics, provide information stratified by individual characteristics such as gender, age, race, and ethnicity. Maternal mortality is a prime example. The maternal mortality rate for the United States in 2020 was 23.8 deaths per 100,000 live births; however, maternal mortality rate for non-Hispanic Black women was 55.3 deaths per 100,000 live births, 2.9 times the rate for non-Hispanic White women.39 By identifying a large disparity in maternal health for non-Hispanic Black women, clinicians and policy makers can increase awareness and focus efforts on at-risk populations.

An eloquent discussion of race-related bioethics proposes race-conscious approaches to support principles of justice and respect for equitable care.40 Like public health research, clinical research is also moving toward race-conscious approaches that align with similar clinical ethical practices. Several scholars promote research that accounts for the effect of racism, going beyond simplistic approaches that include race without understanding the actual experiences of minority individuals. There is also a recognition of the need to study discriminatory policies and how these fundamentally affect the health of individuals; for example, redlining in real estate and the exclusion of undocumented immigrants from the health care system.40

Color Blindness and Racial Discrimination

Since 2012, a taskforce from The American Psychological Association (APA) identified CBRT as a manifestation of racial discrimination. This task force specifically cited CBRT as unrealistic and harmful, given that we live in a society that clearly is stratified by race. It also highlighted how CBRT reinforces racial prejudice and inequality by negating individual’s race, race-experiences, and policies supported by institutional racism and concluded that CBRT is a modern expression of racism.

As clinicians and researchers, anesthesiologists are called to better understand the implications of CBRT in the health of our patients and in the advancement of science. We cannot continue to ignore the effect of race on people’s health and health outcomes.

DISCLOSURES

Name: Brittany L. Willer, MD.

Contribution: This author helped with the idea conception, critical review of literature, initial writing of the manuscript, and manuscript revision and approved the final manuscript.

Name: Emmanuel Alalade, MD.

Contribution: This author helped with the idea conception, manuscript preparation, and manuscript revision and approved the final manuscript.

Name: Paloma Toledo, MD, MPH.

Contribution: This author helped with idea conception, as well as the review of literature, and critically reviewed and revised the manuscript and approved the final manuscript.

Name: Nathalia Jimenez, MD, MPH.

Contribution: This author helped with idea conception, critical review of literature, and manuscript preparation and revision and approved the final manuscript.

This manuscript was handled by: Olubukola O. Nafiu, MD, FRCA, MS.

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