Taking notice of race is both risky and inevitable, in medicine no less than in other endeavors. The literature on race as a classifying tool in clinical research poses this core dilemma: On the one hand, race can be a useful stand-in for unstudied genetic and environmental factors that yield differences in disease expression and therapeutic response. On the other hand, racial distinctions have social meanings that are often pejorative or worse, especially when these distinctions are cast as culturally or biologically fixed. Our country's troubled past in this regard and the persistence of race-related disadvantage should keep us on notice about this hazard. Yet paying attention to race in order to ameliorate past wrongs sometimes supports the quest for social justice, as Dorothy Roberts points out in this issue. And at times, as Jay Cohn and Raj Bhopal note, attention to race can make a therapeutic difference, to the point of saving lives.

Critics of international trade agreements often cast them as threats to human health, and they can point to some sobering warnings from world history. Infectious diseases have swept across political boundaries, carried by traders, colonists, and other agents of globalization. Transnational epidemics have laid economies low, undermining political stability. The spread of viruses and bacteria to peoples previously unexposed and therefore lacking immunity has decimated populations and changed the political course of continents. Trade, exploration, and warfare have repeatedly produced encounters between peoples at different levels of agricultural and technological development. Often, the results have been devastating for the disadvantaged group — economic marginalization, loss of sovereignty and culture, and collapse of public health. Yet the rise of civilization — plant and animal domestication, division of labor, technology, and resulting prosperity — was powered in large part by movement of products and knowledge along routes of trade and migration.

The Institute of Medicine Report, Unequal Treatment: Confronting Racial and Ethnic Disparities, affirms in its first finding: “Racial and ethnic disparities in healthcare exist and, because they are associated with worse outcomes in many cases, are unacceptable.” The mechanisms that generate racial and ethnic disparities in medical care operate at the levels of the healthcare system and the clinical encounter. Research demonstrates the role of healthcare system factors, including differences in insurance coverage and other determinants of healthcare access, in producing disparities. Research also shows, however, that even when insurance status and other measures of access are controlled for by statistical methods, racial and ethnic disparities persist. These disparities remain when researchers try by various methods to control for patients’ clinical characteristics. Disparities are especially well documented through comparisons between white patients and African Americans and Latinos, but they are believed to affect other minority groups. As a result, many members of minority racial and ethnic groups receive less or inferior care.

A chilling subplot in the twentieth-century saga of state-sponsored mass murder, torture, and other atrocities was the widespread incidence of medical complicity. Nazi doctors' human “experiments” and assistance in genocidal killing are the most oft-cited exemplar, but wartime Japanese physicians' human vivisection and other grotesque practices rivaled the Nazi medical horrors. Measured by these standards, Soviet psychiatrists' role in repressing dissent, Latin American and Turkish military doctors' complicity in torture, and even the South African medical profession's systematic involvement in apartheid may seem, to some, almost prosaic. Yet these and other reported cases of medical complicity in human rights abuse compel an inquiry into medicine's vulnerability to becoming an adjunct to illicit state purposes.

To the surprise of many and the dismay of some, the U.S. Supreme Court took it upon itself last term to proclaim a national compromise on the question of abortion. The Court's announced truce, an elaboration on Justice O’Connor's “undue burden” idea, is pragmatic in design but unlikely to prove stable in practice. The three justices who spoke for the Court disparaged Roe with reluctant praise, then upheld its outer shell on the ground that social expectations and the need to sustain the appearance of the rule of law made it impolitic to do otherwise. This awkward doctrinal invention seem unlikely to yield a lasting peace. However artful as political brokerage, it is unpersuasive as principled jurisprudence. Its explicitly political calculus invites skepticism about its authors’ commitment to principled method even as it purports to preserve public regard for judicial legitimacy. Moreover, there is an unexplained “disconnect” between the opinion's avowed preservation of Roc's “essential holding” and its abandonment of Roe's commitment to reproductive freedom as a compelling interest.