AMA Journal of Ethics^®

In December 2002, the United States Supreme Court accepted 2 cases, Gratz v Bollinger and Grutter v Bollinger, that take up the use of race and ethnicity as factors for consideration in admission to the University of Michigan's undergraduate program and law school, respectively. The Court is expected to make a momentous decision this month regarding the constitutionality of using racial preferences in admissions policies, a decision that could affect admissions policies in all forms of higher education including medical schools.

Dr. Jordan J. Cohen, current president of the Association of American Medical Colleges, defends the continuation of affirmative action admission policies in a recent JAMA article. The Consequences of Premature Abandonment of Affirmative Action in Medical School Admissions.¹ He argues that affirmative action in medical schools remains necessary at this time to educate an ethnically and racially diverse physician workforce. He offers 4 reasons why diversity is important and states that medical schools have an obligation to select and educate a future physician workforce that can respond to a diverse patient population and to society's evolving health care needs.

With a growing minority population in the United States, medical schools must select and train an ethnically diverse physician workforce to better understand how individuals from different cultural backgrounds interpret and experience illness and disease. Medical students need more than textbook and classroom learning to grasp how cultural factors influence patient care. Cohen states that diversity among students and faculty is indispensable in offering quality medical education where students interact with mentors, peers, and patients of diverse racial, ethnic, and cultural backgrounds and varying worldviews. He firmly believes that prohibiting admissions committees from using affirmative action admissions policies is likely to set up medical schools--and future physicians--for failure in fulfilling their contract with society.

Cohen stresses that a racially and ethnically diverse physician workforce is critical to improving access to care and widening the scope of medical research with minority populations. In his article, Cohen cites several sources, which document that underrepresented minority (URM) physicians are more likely to devote their careers to working with underserved and uninsured populations. He also suggests that because investigators tend to research problems they have observed or experienced within their cultural sphere, universities must ensure diversity in their MD and PhD programs to advance and broaden research in medicine and public health.

Another reason for supporting affirmative action, in Cohen's opinion, is that it makes good business sense to create diversity among managers of health care organizations. He suggests that a diverse group of physician leaders and managers may better anticipate the needs of and deal effectively with individuals from a wide variety of backgrounds and, thus, ensure the success of the organization that they direct.

Cohen believes the best way to achieve the above-mentioned goals is through affirmative action admissions policies. Without these policies, the proportion of URM applicants (African Americans, Mexican Americans, Native Americans, and mainland Puerto Ricans) will drop, as happened during the late 1990s when a series of court and legislative activities (ie, California's Proposition 209, Hopwood v Texas, Initiative 200 in Washington state) outlawed schools from giving any consideration to the racial and ethnic backgrounds of their applicants.

URM applicants often have lower GPAs and MCAT scores than their white and Asian American counterparts and have less chance of being admitted on academic credentials alone. Cohen points out, however, that "to be more qualified than someone else for admission to medical school is not simply a matter of having higher grades or MCAT scores."² Admissions committees also scrutinize applicants for less quantifiable qualities such as evidence of leadership, overcoming adversity, capacity for hard work, commitment and willingness to serve others, particularly the underserved, and ability to communicate effectively. Cohen stresses that, over the years, admissions committees have become adept at selecting highly qualified minority applicants who have less than stellar GPAs and MCAT scores. He further adds that there are several assessments during medical school that minimize the possibility of awarding a medical degree to an unqualified individual.

In his support of affirmative action, Cohen acknowledges critics of affirmative action who argue that the acceptance of minority students with lower academic credentials is a form of racism and contend that only by maintaining equal standards for all will minority students, over time, excel on their own. While Cohen admits the possible validity of this theory, he believes that it calls for an unrealistic "rapid reversal of deeply rooted societal and cultural norms" to close the diversity gap in medicine.³ He suggests that removing race-conscious admissions policies requires remedying unequal educational opportunities, eliminating cultural disparities, significantly reducing economic barriers, and removing more subtle forms of discrimination. He further asserts that other alternatives such as "percentage plans," in which every high school's top graduates are guaranteed college admissions, and other surrogate markers such as living in a low-income zip code, coming from a disadvantaged family background, having overcome adversity, or expressing a willingness to serve the underserved simply do not guarantee the intended outcome of achieving racial and ethnic diversity.

Although Cohen admits that, ideally, race would not be a consideration in medical school admission, he supports race-conscious admissions policies as the best answer to the need for diversity among students in medical education at present.

Questions for Discussion

1. Do you agree with Cohen's 4 reasons for ensuring diversity in medical schools?
2. Do you think that affirmative action admissions policies are the only means of achieving such diversity?
3. Cohen suggests that the abolishment of affirmative action would be premature. At what point (if any) would it be appropriate to consider outlawing affirmative action? How would we assess when that point has or will be reached?
4. Do you agree that affirmative action actually reinforces racism by suggesting that URMs need a more lenient set of qualifications?