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

“This book lays bare a disturbing contradiction. On one hand, injustice and inequality are anathema to our professed national identity. Yet on the other hand, unconscious bias has become an entrenched and acceptable social norm, empirically demonstrated to control decision-makers not only in health care, but in civil and criminal justice proceedings, law enforcement, employment, media, and education. Unconscious racism has become the new normal. Thus, to defeat inequality due to unconscious racism in health care, individuals as well as institutions must realign themselves away from this social norm that is incongruous with the core underlying values to which our nation’s doctors, patients, and health care professionals expressly aspire. The solutions this book proposes are comprehensive; they have their origin in law, and to some this may seem radical. But they are solutions grounded in a historical and empirical record.”

In her introduction, Matthew discusses the troubling paradox between America’s professed commitment to justice and the pervasive influence of unconscious bias, which subtly perpetuates racial inequality across multiple sectors. She argues that unconscious racism has become so normalized that it undermines the values of fairness and equality, particularly in healthcare, emphasizing The Systemic Challenge in Addressing Implicit Bias. Matthew asserts that addressing this systemic issue requires a fundamental shift in both individual and institutional practices, grounded in legal reforms that challenge entrenched biases.

“Tragically, the American legal system began during colonial times to sow the seeds of health inequality. The weak legal regime that currently regulates modern health care delivery continues to provide fertile ground for rampant health care discrimination today. Throughout most of our country’s history, the rule of law has been perversely instrumental in enabling the racism—both conscious and unconscious—that has produced, and continues to exacerbate, the unjust distribution of health care, as well as other resources that permit people to live healthy lives, such as property, wealth, income, housing, food, employment, and education.”

Matthew critiques the American legal system for being complicit in fostering health inequality. Throughout the book, Matthew makes a case for recognizing the historical roots of racism in America’s institutions. She emphasizes that the current legal framework remains inadequate in addressing these inequalities, perpetuating discrimination in healthcare delivery.

“Taking together the discriminatory property, housing, labor, and immigration laws that prevailed during our nation’s early history, we can make a strong case that these inequitable restrictions on access to the most basic social determinants of health directly contributed to the inferior health status indicators that minorities continue to suffer today. However, as the nation entered the twentieth century, legal restrictions extended beyond the social determinants of health, and the American legal system became directly and overtly hostile to minority health. Legalized racial discrimination in health care added to the derivative impact that more general laws had on minority health during the colonial and post–Civil War periods.”

Matthew highlights how early discriminatory laws laid the foundation for persistent health disparities among BIPOC populations by limiting access to vital social determinants of health. This analysis suggests that the legal system not only failed to rectify historical injustices but actively contributed to the worsening of health outcomes for marginalized communities over time.

“Americans now seldom espouse the overt racism, prejudice and bigotry that our laws prohibit. To be clear, direct and explicit racial bias still exists and operates to cause discrimination in health care delivery today, as it does elsewhere in America. For example, the ugly choice to believe that African Americans as a people group are inferior or uniformly uneducated when compared to whites or to assume a priori that Latinos do not deserve to benefit from American health care because they are ‘illegals’ still motivates some physicians to give better medical care to their white patients than they do to their black or Hispanic patients. However, this type of overt racial prejudice and racism has dramatically declined over the past half-century and is no longer the predominant mechanism by which health care discrimination occurs.”

In recognizing that overt racial discrimination has dropped in the last decades, Matthew sets the stage for her argument regarding The Role of Implicit Bias in Healthcare Disparities. Despite the decline of overt racial prejudice, racial discrimination practices in healthcare persist. Therefore, Matthew argues, unconscious bias has replaced more overt types of discrimination.

“Physicians strive to limit their exercise of discretion to considering only the facts that are empirically supported and medically relevant. They take into account race or ethnicity in the course of a patient’s care only when, and to the extent that, those factors are relevant to diagnosis and treatment. For example, racial cues can influence medical decisions appropriately where family history, disease etiology, epidemiological patterns, sociological influences, and anthropologic data are concerned. In those cases, race and ethnicity can have rational bearing on treatment. […] However, a vast body of social science research describes hundreds of experiments, in scores of medical journals, across virtually every major medical specialty that confirm that a patient’s race and ethnicity continue to influence physicians’ medical conduct and decision-making, well beyond the limits of what is clinically justifiable. The incongruence of these findings and the expressed race neutrality, education, scientific training, and ethical commitment of physicians is baffling.”

Matthew exposes a significant contradiction between physicians’ intent to base medical decisions on clinically relevant data and the reality of how race and ethnicity still influence care beyond medical necessity. She emphasizes that while race can be relevant in specific contexts such as epidemiology and family history, social science research reveals a troubling pattern of racial bias affecting treatment decisions in ways that are not clinically justified and, often, detrimental to the patient. This disparity challenges the notion of race neutrality in medicine and calls into question the effectiveness of medical education and ethical commitments in preventing unconscious bias.

“When a patient arrives in the hospital, clinic, or doctor’s private office for a check-up, all of the patient’s experiences and expectations arrive, too. Whatever the physician does will be filtered through those experiences, and the patient’s implicit biases will influence his perceptions, decisions, and conduct. In turn, the doctor, having stored her own stereotypes as well, may ‘read’ the patient’s behavior through the lens of her unconsciously held stereotypes. The reciprocity is not only circular but duplicative.”

Matthew highlights the complex and reciprocal nature of implicit bias in the physician-patient relationship, where both parties bring their own unconscious prejudices that shape their perceptions and interactions. This feedback loop reinforces stereotypes and amplifies the biases on both sides, creating a circular dynamic that influences medical outcomes and decision-making. By emphasizing the dual presence of bias in both doctors and patients, Matthew stresses the importance of recognizing and addressing these biases to break the cycle.

“Yet physician’s implicit bias discrimination does not rise to the level of a legally significant offense. Notwithstanding a national consensus that racism is wrong and a plethora of antidiscrimination statutes and regulations currently on the books, the existing law takes virtually no notice of discrimination that is the result of unintentional beliefs or conduct. In general, the United States Constitution as well as federal and state statutory laws strongly prohibit only intentional discrimination based on race, national origin, gender, age, disability, or the fact that a person is an immigrant to this country. When the discrimination against members of these protected classes of people is unintentional, the legal remedies available are few and difficult to access.”

In this quote, Matthew critiques the legal system for its failure to address implicit bias in healthcare, emphasizing that unintentional discrimination, despite its harmful effects, often escapes legal scrutiny. This disparity reveals a disconnect between the moral consensus against racism and the legal framework’s limited ability to provide remedies for the more pervasive, subtle forms of discrimination that still affect marginalized groups, highlighting The Importance of Legal Reforms that Address Implicit Bias.

“Few studies have been performed to consider the effect of implicit biases on minority groups other than blacks and whites. And besides the simplistic black and white categories tested, patient characteristics overlap outside and within those categories. Studies do not reflect that white patients may be poor, wealthy, or somewhere in between, while black patients may have light or dark complexions, even though all these variations have been shown to impact implicit bias levels. All patients possess overlapping characteristics. Their gender, age, geographic origin, and countless other characteristics are also prone to trigger physicians’ implicit biases and stereotypes, but few other traits have been tested independently or as they overlap with one another.”

In this quote, Matthew emphasizes the need for more nuanced research that examines how overlapping patient traits trigger implicit biases, as these variations shape healthcare experiences and outcomes. The lacuna in research show that there is already a discriminatory mindset at work, which plays down all other differences, while emphasizing the most obvious color differences and preconceived ideas about social and racial groups.

“The Biased Care Model identifies six mechanisms by which physician and patient implicit biases operate to produce disparate health outcomes. I offer the model to synthesize the complex empirical literature on health disparities. My objective is to provide a set of general principles that will help predict the interactions that are the most likely source of increasing health disparities. These principles will help inform future applications of the accumulated research record on health disparities. Social and clinical scientists have generated a veritable mountain of data examining the problem for a variety of patient populations, clinical settings, and illnesses. However, this vast literature lacks a theoretical framework to turn these data into a practical approach to addressing the egregious inequity problem.”

Matthew introduces the Biased Care Model as a theoretical framework aimed at organizing and interpreting the complex empirical data on health disparities. By identifying six key mechanisms of implicit bias, her model seeks to pinpoint interactions that are most likely to worsen health inequities, offering a predictive tool for addressing these disparities. Matthew critiques the existing body of research for its failure to translate extensive data into actionable strategies, positioning her model as a means to bridge that gap and provide a more practical approach to tackling systemic healthcare inequity.

“Note this physician’s reference to the ‘surprise’ of finding that her black patient belonged to a prominent family. Note further that she would not have been surprised at the affiliation if that patient were white. And finally note the ever-so-subtle admission that her disposition toward her black patient changed once she realized his connections. This physician is more than just ‘well-intentioned’ as her willingness to ‘bend over backwards’ confirms: She is committed to fairness and is an outspoken advocate for the underserved. Yet even this physician reserves one approach for black patients who fit her expectation that African Americans are not prominent or well connected, but shifts her demeanor if she encounters an individual who defies this expectation. These are not behavior choices she attaches automatically to white patients, and so it is clear these are expectations about race and not class.”

Matthew includes her interviews with healthcare professionals to illustrate how even well-intentioned physicians can unconsciously hold and act on racial biases, as demonstrated by the physician’s surprise at her black patient’s status. Despite her commitment to fairness and advocacy, the physician’s shift in treatment reveals that her preconceived expectations about black patients influence her behavior. Matthew underscores that these biases are rooted in racial rather than class-based assumptions, emphasizing that deeply ingrained stereotypes shape medical interactions, even when professionals are dedicated to equality.

“The problem, as one researcher has put it, is not with the use of classification and heuristics that are common and helpful in medicine, but with ‘fixed, untrue stereotypes resistant to modification [that] threaten the accuracy of decision-making.’ Physicians have been shown to allow stereotypes about minority patients to override the medical facts, their own good intentions, and even their medical training.”

While Matthew defends the use of science-based methods, such as classification, she notes that ingrained biases can lead physicians to prioritize stereotypes over objective medical data, undermining both their intentions to provide equitable care and the effectiveness of their medical training. This inherent conflict further reinforces Matthew’s argument for solutions specifically aimed at addressing implicit bias.

“There is ample evidence that physicians’ physical clinical conduct, influenced by automatic racial prejudices and stereotypes, affects the quality of their verbal and nonverbal communication with patients. Moreover, studies reveal that the way that doctors behave and communicate has an impact on patient health outcomes. Implicit biases affect doctors’ nonverbal and verbal signals. Some of the best evidence confirming this comes from medical students. Student physicians make keen observers because their objective is to learn from the example set by their physician instructors. Thus, in the clinical setting, medical students stand shoulder to shoulder with physicians at a patient’s bedside, watching both the physicians and the patients interact.”

Matthew suggests that biased communication patterns, reinforced through clinical teaching, perpetuate disparities in healthcare, as students unconsciously adopt these prejudiced behaviors in their future practice. Matthew illustrates how, when not addressed directly, unconscious bias replicates and perpetuates discriminatory practices via learned behavior.

“Interviews with minority female patients pointed to an additional feature of physician conduct and communication that reflects unconscious racism. Several women reported that their narratives were discounted, disbelieved, or simply ignored by physicians who seemed committed to a stereotype of minority women patients. A commonly repeated narrative was the experience of being told ‘you are fine’ despite evidence of debilitating pain.”

Matthew provides specific examples that illustrate how the intersection between race and gender can amplify discriminatory practices. In this passage, she uses the experience of minority patients, whose concerns are often dismissed due to entrenched stereotypes. This behavior, Matthew suggests, reflects a deep-rooted bias that invalidates the lived experiences and suffering of minority women, undermining their trust in the healthcare system.

“The tragic message of Mechanism 4 is that during the clinical encounter, patients react to physician bias with biased communication and conduct of their own to the detriment of their health outcomes. Perhaps the single most telling data point is that African Americans and Latinos use health services at lower rates than their white counterparts, even after differences in their initial access to care, diagnosis, and illness severity are controlled. That bears repeating. Health outcome and health care disparities do not appear to arise solely because minorities have disparate access to health care. Even when black and Latino patients have the same access to healthcare as their white counterparts, the minority patients do not use the health care they have as frequently as whites do.”

Matthew highlights a damaging cycle in which patients respond to physician bias with biased behaviors of their own, which negatively affects their health outcomes. She emphasizes that the underutilization of healthcare services by BIPOC patients persists even when they have the same access as white patients, which confirms that the issue goes beyond access alone. Matthew point suggests that biased interactions during clinical encounters contribute to a lack of trust and engagement with the healthcare system.

“Implicit bias must be suspected as an explanation for why primary care physicians who treat predominately black patient populations more often report that they are unable to provide access to high-quality care than those who care for predominately white patient populations. Specifically, these practitioners report more difficulty making referrals to high-quality subspecialists, high-quality diagnostic imaging, non-emergency hospital admissions, and high-quality ancillary services. Disparate treatment decisions involving the care mental health patients receive must be reviewed in light of the pervasive findings of implicit bias among physicians. For example, studies have shown that minorities may be more frequently exposed to treatment decisions that can cause injuries, such as the decision to use restraints.”

Matthew illustrates the ways bias can manifest in reduced access to quality referrals, diagnostics, and hospital services for BIPOC patients, underlining the practical stakes for marginalized patients. Matthew emphasizes the need to reevaluate treatment decisions, particularly in mental healthcare, where implicit bias may lead to harmful practices. The data that Matthew discusses points to a pervasive issue that undercuts the BIPOC patients’ access to the highest quality of healthcare.

“Again, returning to the language of sociologists, disruption of the fundamental association between unconscious racism and inferior health outcomes requires a radical transformation, not merely changes in the resources, knowledge, or access to care that has been the focus of American health policy during the past two decades. The Biased Care Model is designed to contribute to such a radical transformation by explaining the process by which implicit racial bias works to drive the causal relationship between unconscious race discrimination and disparate health outcomes. And while there remains a need for future research to understand exactly how each mechanism contributes to disparities, the currently available evidence is enough to compel life-saving reforms.”

Matthew argues that addressing the link between unconscious racism and health disparities requires a radical overhaul, rather than incremental improvements in resources, knowledge, or access to care. She positions the Biased Care Model as a tool to help explain how implicit racial bias fuels these disparities, advocating for systemic change beyond traditional health policy approaches. Despite gaps in understanding all contributing mechanisms, Matthew urges the readers and policymakers to trust the evidence she cites abundantly in her book.

“In addition, pain is difficult to quantify. Physicians rely upon imprecise questions such as ‘Can you rate your pain on a scale from one to ten?’ while knowing that no two individuals have identical scales. At the same time, the danger associated with potential drug abuse and addiction raises the stakes for physicians who seek to prescribe narcotic pain medicine only when necessary, justifiable, or appropriate. Thus, the combination of clinical uncertainty and perceived risk places great weight on the physicians’ ability to make judgments about the patients’ honesty and likelihood of compliance, and increases the probability that physicians will use racial, ethnic, and other stereotypes to make difficult judgments and predictions about patients’ behavior.”

Matthew uses pain management as a prime example for how unconscious bias and discrimination practices operate. The subjective nature of pain assessment, combined with the stereotypes connecting BIPOC patients with drugs, increases the reliance and pressure on physician judgment. This reliance, due to clinical uncertainty, often leads physicians to unconsciously use racial and ethnic stereotypes when determining a patient’s honesty and compliance, evidencing The Role of Implicit Bias in Healthcare Disparities.

“Thus, in some studies, evidence strongly suggests that automatic stereotyping results in inadequate pain treatment in clinical settings where negative aspects of racial biases are reinforced. For example, inner-city emergency rooms with large indigent populations generate higher levels of unconscious bias among physicians than settings where the case mix is more diverse. In any settings, however, stereotypes can falsely appear to provide clinically relevant information to the decisions doctors make to treat pain. The physician may call upon stereotypes about low-income patients’ access to pharmacies or about the incidence of drug abuse by African Americans when making decisions about pain treatment. […] In truth, any stereotypes overlap imperfectly with the information doctors need to treat pain; they also introduce dangerous implicit biases into medical decision-making.”

Matthew illustrates how automatic stereotyping, particularly in environments like emergency rooms, contributes to inadequate pain treatment due to the reinforcement of negative racial biases. She argues that stereotypes, such as assumptions about drug abuse or low-income patients’ access to care, do not provide useful clinical information but distort medical judgment. These biases fail to align with the medical facts needed for effective pain management and introduce harmful errors in decision-making.

“After Mr. Thompson is turned down for thrombolysis treatment, he is unlikely to receive adequate medication for his chest pain as he departs the cardiologist’s office. If he returns to his primary care provider, he is less likely than a white patient to receive educational counseling about smoking cessation, moderating his diet, and increasing exercise, because his providers are likely to assume that Mr. Thompson is not well-educated enough, wealthy enough, or motivated enough to benefit from this type of life-prolonging counsel. […] Ultimately, Mr. Thompson is likely to die several years before a white patient with the same initial medical condition. In short, because we assume that nothing can be done to mitigate unconscious racism in health care, the length and quality of Mr. Thompson’s life still depends on whether his skin is black, brown, or white.”

In this quote, Matthew provides a typical narrative of a BIPOC patient, called fictively “Mr. Thompson.” Her narrative illustrates a chain of medical decisions that lead to a catastrophic consequence for Mr. Thompson: an earlier death than that of a white patient with the same affliction. Matthew emphasizes the degree to which this chain reaction is driven by the physician’s unconscious bias—the discriminatory assumptions based on Mr. Thompson’s race—highlighting the stakes of leaving implicit uninterrogated.

“The importance of understanding that implicit biases are malleable cannot be overstated. First, malleability means that interventions may be strategically introduced to provide current inputs that alter implicit biases. Thus, we can expect that implicit biases can be reduced. To say that biased attitudes may be “reduced” is to say that current informational inputs can be adjusted so that the resulting stereotype patterns no longer conform to traditional, discriminatory, or inequitable stereotypes, but instead lead individuals and institutions to more equitable judgments and more equitable conduct. Furthermore, malleability also means that the discriminatory impacts that result from implicit biases also may be reduced.”

Matthew emphasizes the idea that implicit biases are not fixed but malleable, suggesting that strategic interventions can effectively alter and reduce these biases—a central tenet of her argument in Just Medicine. By adjusting the information and experiences that shape these biases, individuals and institutions can move away from discriminatory patterns toward more equitable decision-making and behavior. This malleability offers hope for mitigating the harmful effects of implicit biases, ultimately reducing their impact on health disparities.

“Researchers’ recommendations dramatically underestimate the structural constraints on individual change and the concomitant need for macrolevel interventions to address health disparities. Because the dominant social cognitive theory explains these individual attitudes as inadvertent, inevitable, and ubiquitous, the literature makes unconscious racism seem irrational and exceptional. In truth, researchers have missed the very rational, functional, and structural bases for racism in America and in American health care. The systemic divisions by race and ethnicity in health care preserve power and protect the institutional health care delivery system from economic and social destabilization.”

Matthew argues that unconscious racism is not merely irrational or exceptional but has a long and persistent history, which should be acknowledged and brought to light. To this effect, Matthew calls for interventions that recognize and dismantle these entrenched systems that continue to reinforce inequality and protect the status quo.

“I propose changing the context in which health care delivery occurs by reforming antidiscrimination law. Legal reforms will impact social norms and will incentivize long-lasting protective interventions by institutional health care providers. Institutions will create a climate for change because they will be corporately incentivized to articulate nondiscriminatory goals clearly and adopt compliance policies, procedures, and infrastructure to implement nondiscriminatory training, assessment, and enforcement. The solution I propose is designed to maximize the population-wide impact of reducing implicit biases, while also requiring individual effort to address the cognitive formation of these biases and the discriminatory conduct that they inspire.”

Matthew advocates for reforming antidiscrimination law as a means to reshape the context of healthcare delivery and promote systemic change. By legally incentivizing healthcare institutions to adopt clear policies against discrimination, she envisions a shift in social norms that would encourage the reduction of implicit biases across the system. Her proposal emphasizes a dual approach, addressing both institutional frameworks and individual efforts.

“The changes to the Title VI statute that I propose will serve three objectives in reforming the delivery of health care. First, the substance of the new antidiscrimination law will accurately account for the copious scientific evidence that instructs how to control unconscious discrimination harms. Second, the proposed legal reform will incentivize evidence-based structural changes in health care practice that will mitigate the influence implicit biases have through each of the six mechanisms of the Biased Care Model. And third, reforming Title VI will leverage the expressive role of law to meaningfully shift the social norm that presently tolerates unconscious racism in health care. Overall, the reforms proposed here will operate to align provider and patient behavior with core American social values of equality and justice.”

Matthew summarizes her position regarding reforming Title VI statute of the Civil Rights Act: she wishes to align legal standards with the growing body of scientific evidence on controlling bias. Matthew emphasizes the law’s power to influence social norms, suggesting that reforming Title VI will help shift societal tolerance of unconscious racism—a practical example that underscores The Importance of Legal Reforms that Address Implicit Bias.