The n e w e ng l a n d j o u r na l of m e dic i n e

P oin t s of V ie w

Am I Racist?
R. was a teenager when his osteosarcoma came
roaring back, with vertebral metastases that left
him paralyzed and bed-bound. He’d been told
he was going to die, but his mother, a tower of
strength, was determined to keep things positive.
During home visits, she stood guard, making
sure my team and I were never alone with him
and diverting any conversation that came close
to the question of what he knew or wanted to
know. That part of him belonged to her. Though
we told her resuscitation was inadvisable, that
was a limit she couldn’t set and a conversation
we couldn’t have.
So our brief visits focused on symptoms, and
his condition slowly worsened. One day, he just
wore out. Whether he was dying or just had a
long premonitory respiratory pause, we’ll never
know. A young woman in the home, witnessing
this pause, jumped to perform chest compres-
sions. Whether owing to a panic-induced energy
surge or the delicate, thinning skin of a cachec-
tic, dying young man, her maneuver ripped the
skin off R.’s emaciated chest. When the ambu-
lance arrived, he was breathing again, and when
I saw him in the emergency room, he was awake
and responsive. Under his shirt, a broad swath
of skin was missing, his chest all glistening fat
and oozing blood.
I told his mother we would admit him, tend
to his wound, and send him home the next day.
But unable to imagine compressing that open,
broken chest, I said that if he had a cardiopul-
monary arrest, we would not attempt resuscita-
tion. Wide-eyed, she nodded. I told R., and he
nodded too. I completed the paperwork docu-
menting his DNR status.
When I got home, a resident called to say that
R.’s aunt was furious. How could I make him
DNR without his or his mother’s consent? I
asked to speak with her, and she launched into
a diatribe, informing me that I could not simply
override a patient’s and family’s wishes: “We’re
Black,” she said, “and we know how the system
works.”
Having lived her life in a system that didn’t
work for people of color, how could she see my
unilateral decision making in any other way? Yet
as I returned to the hospital to continue the
conversation in person, I thought if ever there
was a situation in which resuscitation would be
horribly painful and ineffective, this was that
time. If ever there was a time to be directive and
remove the burden of that decision from a fam-
ily, this was that time. And had I not in some
fashion obtained their consent?
Or perhaps R.’s mother’s nod was actually the
shell-shocked gaze of an overwhelmed parent,
and I saw a nod so I could assure myself it was
a shared decision. As for R., he’d just been resus-
citated and whisked off in an ambulance — how
much of what I said did he really understand? If
he’d been an affluent White teenager, would I
have done the same thing? I thought so, but R.’s
family was unconvinced, and their experiences
justified their skepticism and anger.
Though my parents were outspoken advocates
for racial equality, I grew up in Memphis in the
1950s and 1960s. Its ugly culture of segregation
surely left its mark on me in ways I’ve done my
best to deny. When I scored “moderate prefer-
ence for White people over Black people” on the
Harvard Implicit Association Test, I took it again
— and got the same result. I can’t just selec-
tively acknowledge the influences of my forma-
tive years that convince me I make unbiased
medical decisions. The uglier forces from my
past play a role. Are we not all messy amalgams
of life experiences good and bad, conscious and
unconscious?
When I got back to the hospital, R. was dying.
His breathing peacefully slowed to a halt, and
his mother tearfully let him go. The conversation
with his aunt never happened, so I will never
know if I would have found the right words.
Though I was relieved, the family’s doubt lingers.
I suspect the implicit bias I wrestle with is
explicit in their eyes. Though I can’t know for
sure what I would have done if R. had been

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The New England Journal of Medicine
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 The n e w e ng l a n d j o u r na l of m e dic i n e

White, denying that my past affects my thinking David N. Korones, M.D.

is not the answer to such heart-breaking dilem- University of Rochester Medical Center
mas. I need R.’s family’s perspective to help open Rochester, NY
Disclosure forms provided by the author are available at
my eyes to the world they see. I can only hope NEJM.org.
that when I’m again challenged on the wisdom This article was published on September 1, 2020, at NEJM.org.
of my decisions, I can ask the same questions of DOI: 10.1056/NEJMpv2024766
myself that they asked of me. Copyright © 2020 Massachusetts Medical Society.

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