Critical Race Theory and Medical Education

Stephen R. C. Hicks, Department of Philosophy, Rockford University, Illinois, USA 61108

[Invited comment on J. Tsai, “Building Structural Empathy to Marshal Critical Education into Compassionate Praxis: Evaluation of a Peer-Led Critical Race Theory Course,” for Journal of Law, Medicine, and Ethics, Special Issue on “Race and Ethnicity in 21^st Century Health Care,” edited by Robert M. Sade, M.D., Vol. 49, forthcoming 2021. SSRN link.]

Commentary

Tsai’s article[i] makes five claims: Biological essentialism the problem as it is both false as a scientific theory and gives rise to “dehumanization and discrimination.” But current medical education “continually” teaches biological essentialism and so healthcare students are “constantly exposed” to it. By contrast, Critical Race Theory (CRT) is “uniquely equipped” to solve this problem. A course for healthcare students that applied CRT achieved good results against racism.

I have, correspondingly, five brief comments in response to Tsai’s article, which is a generally clear statement of CRT and an educational experiment based upon it, yet is marked by theoretical overstatements and a series of binary contrasts that understate the range of options in combatting racism.

Soft and Hard Critical Race Theory

A standard challenge on normatively charged issues is linguistic. Any sub-field of the theoretical literature has its technical terms, but there is an additional problem in normative literatures that deploy value-laden concepts that mean something very different from mainstream uses. In the CRT literature, inequity, power, structure, oppression, social justice are examples. So extra effort should be made to avoid both miscommunication as well as the appearance of motte and bailey rhetorical strategies.[ii]

Sometimes CRT is taken softly, as the position that a heightened awareness of racial issues is morally obligatory, as is an explicit recognition of ongoing problems of racism and a commitment to solving them. Here the foil is an ignorance or complacency about racial issues.

Yet hard versions of CRT also exist, in which the above concepts are given packaged collectivized and adversarial definitions to be deployed against their intellectual adversaries. For example, structural racism depends on a specific meaning of structural developed in this literature. Here is a standard statement:

“In this century, the move towards structuralism in many disciplines has been a (secular) seeking out of hidden rules that regulate human behaviour. Structuralist approaches challenge the humanist concept of the self as an autonomous agent by laying bare the extent to which its apparently free choices are predetermined.”[iii]

Note that such structuralism rules out conscious, intended, and/or explicit rules in favor of hidden determining rules, as well as ruling out autonomous individuals as the agents of thought and action. This generic structuralist account can then be customized to specific group domains, whether race structures or sex-gender structures or class structures are taken to be determinant. The critical element is the assumption of a cognitive ability to identify and attack those hidden-but-determining structures.

Hence Critical Race Theory’s foils are the several philosophies that define racism differently, diagnose differently its causes, weight differently its severity, and propose different solutions. But while those several philosophies must also be grappled with, hard CRT’s conceptual vocabulary tends to set them aside as a monolithic block of non-contenders.

In Tsai’s article, her use of biological essentialism does just this.

Biological essentialism as foil

Racisms based on biological essentialism hold that human beings belong to different groups based on discrete and inflexible biological markers. The claim is that each race has distinct biological essence.

But racisms can also be based on biological nominalism, that is, claims that the biological markers lie along an analog spectrum rather than being discrete, and/or that those markers are changeable rather than being inflexible. The claim then is that race is biological but a matter of somewhat arbitrarily drawing grouping lines along a spectrum.

Hence, the biological territory alone is more complicated, so taking essentialism as the foil—e.g., Tsai’s claim that “essentialist thinking correlates with greater dehumanization and discrimination” at most targets one possible biology.

From descriptive biology to normativity

Further, Tsai’s claimed connections between basic biology and normative pathologies are not obvious or even likely.

Consider a non-racial example: I’m open to the claim that Albert Einstein was twice as intelligent as I am. Perhaps the biology of his brain enabled his superior intellectual prowess. I’m also open to the claims that Michael Phelps can swim twice as fast as I can and that the biology of his lung capacity contributed to his superior speed. But none of that biology has to be essentialist. Even if the correct biology is essentialist, it does not follow that that institutional oppression exists because scholarly and athletic accolades are unequally distributed to the Einsteins and Phelpses. Nor do biological difference imply that those two individuals should have extra political rights or moral standing than less endowed individuals such as myself or that I can claim to be suffering dehumanization and discrimination. Nor does it imply that students learning to become healthcare professionals need a special course to unlearn double-standards in order properly to treat Einstein, Phelps, and me as patients. That is, they don’t need to learn that there are no biological differences between the three of us in order to learn that the same ethical standards of care apply.

The points are that the connections between scientific facts and moral standards are much more complicated. And the point is, by analogy, that if one is concerned with pathological attitudes about race in ethics and politics, it is a long and complicated route back to basic biology.

Anti-racism then and now

Part of that complicated route is illustrated by the history of the impressive success we have made in the past three centuries in lessening traditional prejudices and racisms,[iv] virtually all of which pre-existed modern biology. Yet by taking racism to be rooted in biological essentialism and posing only contemporary CRT as the antidote—the problem is “the emphasis on genetic race, rather than institutional racism”—Tsai’s account misses out on at least two significant anti-racist contenders.

A full anti-racist theory will argue (1) that racism exists, posit (2) that racism is caused by X, estimate (3) that racism is a problem of Y size, and propose (4) that Z will solve racism. CRT’s preferred package of specifications of X, Y, and Z are a relative newcomer, a postmodern account entering into competition with pre-modern and modern accounts that have been mobilized against racism since the Enlightenment of the 1700s. Here are three brief summary statements:[v]

1. Updated religious pre-modernists argue: All humans possess a soul and are equal in God’s eyes. Consequently, racism is wrong because of its emphasis upon superficial physicality. And consequently, as persons and aspiring medical professionals, we have a duty of equal care and compassion.
2. Enlightenment modernists argue:  Each individual is a natural person with agency, moral worth, and a right to life. Racism is wrong, accordingly, as any racial differences are less significant or irrelevant to an individual’s moral and political standing. So we each need to make a personal and medical-professional commitment to care and compassion for each individual.
3. Postmodernists, of whom CRT are a sub-group, argue: Humans are divided into socially constructed collectivities, some of which have oppressive power over others. Consequently, racism is a group pathology of dominance and victimization. And consequently, professional compassion requires that members of the dominant groups unlearn their complicit racism.

So should we follow Martin Luther King, Jr., for example whose philosophy combines elements of religious equalism and modern individualism? 

“I have a dream that my four children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character.”[vi]

Or should we follow one the founders of CRT, Richard Delgado, who explicitly rejects MLK’s approach at its basis:

“Unlike traditional civil rights, which embraces incrementalism and step-by-step progress, critical race theory questions the very foundations of the liberal order, including equality theory, legal reasoning, Enlightenment rationalism, and neutral principles of constitutional law.”[vii]

That is the big question, but we don’t find awareness of it in Tsai’s paper.

Education of healthcare professionals.

All of the above is relevant to Tsai’s major claim that “principles of Critical Race Theory are uniquely equipped” [emphasis added] to address any racism built into current medical education. That claim strikes me as unsupported for two reasons.

One is that the course experiment she describes contrast only students who receive CRT training and those with no values training at all. One representative student is quoted as saying: “Our regular curriculum is just like here’s the stuff; here’s the stats; don’t question them; just learn them…[viii] So it may very well be that simply discussing normative issues increases students’ knowledge and sensitivity to them in comparison to students who do not discuss them. It’s not yet clear that CRT’s unique way of discussing those issues is responsible for the benefits.

The second reason adds the fact that other principled anti-racist methods could be as effective or more effective than CRT, and course experiments would need to be run and the results compared to CRT’s. A four-way experiment would look like this:

• Class 1 teaches and applies the following principles against racism in medical education: equality before God, non-judgmentalism, charity, and duty.
• Class 2 teaches: autonomy, self-responsibility, tolerance of differences, and individual rights.
• Class 3 teaches: collective identity, group adversarialism, structural oppression, and fury.  
• Class 4 does not teach any normative issues.

Absent such experiments being done, we are in no position to make strong claims about which approach will have more success is lessening racisms.

We can speculate that rejuvenating collectivities over individualities, as CRT does, runs the risk of rejuvenating racial tribalisms rather than lessening them. And we can speculate that stoking racial anger and guilt, as CRT does, will lead away from the compassion that Tsai desires rather than toward it. But those speculations too need to be put to the experimental test, and the results added to the historical record of non-CRT approaches that have a significant measure of success against racisms.  

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[i] Jennifer Tsai, “Building Structural Empathy to Marshal Critical Education into Compassionate Praxis: Evaluation of a Peer-Led Critical Race Theory Course.” Journal of Law, Medicine, and Ethics; 2021.

[ii]“The motte-and-bailey fallacy (named after the motte-and-bailey castle) is a form of argument and an informal fallacy where an arguer conflates two positions which share similarities, one modest and easy to defend (the “motte”) and one much more controversial (the “bailey”).” Wikipedia;https://en.wikipedia.org/wiki/Motte-and-bailey_fallacy.

[iii] Chris Weedon, Feminist Practice and Poststructuralist Theory, Wiley-Blackwell Publishing;1987;33.

[iv] Maria Krysan and Sarah Patton Moberg, Trends in Racial Attitudes, University of Illinois Systems, https://igpa.uillinois.edu/report/portrait-african-american-and-white-racial-attitudes.

[v] Stephen R. C. Hicks. Explaining Postmodernism: Skepticism and Socialism from Rousseau to Foucault. Scholargy Publishing. 2004; Chapter 1; Chart 1.3:15.

[vi] Martin Luther King Jr., Speech of August 28, 1963. Lincoln Memorial in Washington D.C. http://www.analytictech.com/mb021/mlk.htm.

[vii] Richard Delgado and Jean Stefancic, Critical Race Theory: An Introduction. New York University Press;2001;3.  https://static1.squarespace.com/static/5441df7ee4b02f59465d2869/t/5d8e9fdec6720c0557cf55fa/1569628126531/DELGADO++Critical+Race+Theory.pdf

[viii] Tsai, Figure 2.

[This commentary is also available at Social Science Research Network.]