European Journal of Epidemiology (2007) 22:215–221
DOI 10.1007/s10654-007-9108-3
METHODS
Can ethical reasoning contribute to better epidemiology? A case study
in research on racial health disparities
Inmaculada de Melo-Martı́n1 & Kristen K. Intemann2
1
Division of Medical Ethics, Weill Medical College of Cornell University, 411 E. 69th Street, New York, NY, 10021, USA;
2
Department of History and Philosophy, Montana State University, Box 172320, Bozeman, MT, 59717-2320, USA
Accepted in revised form 2 January 2007
Abstract. A common belief among epidemiologists
and other scientists is that they ought not engage in
ethical evaluation or endorse any particular ethical,
political, or social values while involved in scientific
reasoning. Such values are irrelevant to collecting and
interpreting data and can only lead to bias. This view
is also reflected in scientistsÕ education. The authors
argue that ethical values are crucial to conducting
much epidemiological research. Focusing on epide-
miological research on racial health disparities, they
show that value judgments are inescapable when
Key words: Epidemiology, Ethical analysis, Ethics training, Value judgments
Introduction
It is generally held that epidemiologists and other
scientists ought not engage in ethical analysis or en-
dorse any particular ethical, political, or social values
while involved in scientific reasoning [1–3]. According
to this view, such values are irrelevant to collecting
and interpreting data and can only lead to bias. Of
course, it is widely agreed that ethical considerations
can be important to science in certain ways. For
example, scientists, like any professionals, are con-
strained by ethical obligations such as abiding by
human subject testing regulations, refraining from
fabricating data, or taking credit for the work of
others. In addition, value judgments may be impor-
tant to scientists in their role as public policy advo-
cates as they help inform policymakers or contribute
to decisions about how scientific knowledge might
best be applied [4]. These ways in which values have
been thought to be relevant to science, however, are
fairly peripheral. They occur before and after
the work that scientists do as scientists is complete.
They are not thought to be relevant to the main
work that scientists do: developing and conducting
experiments, or collecting and analyzing data.
This view is reflected in scientistsÕ education. Sci-
entific training typically does not include identifying
and evaluating any ethical, political, or social issues
related to particular research areas. Yet, the impor-
Ó Springer 2007
performing such research. Values are implicit in the
framing of research questions, the identification of
the problem, and the choices of design and method-
ology. By making value judgments explicit, scientists
will be more likely to pay attention to them and thus
assess them in critical ways. Finally, the implications
that this has for scientific training are discussed.
Scientific training should prepare scientists to engage
in ethical reasoning not only because it will make
them more responsible human beings, but also
because it will make them better scientists.
tance of much epidemiological work is often justified
in relation to ethical and social goals: eliminating
diseases, improving patient care, and using resources
more effectively and efficiently. The assumption,
however, is that these goals have no implications for
how epidemiological research is conducted or how
scientists reason.
In this paper, we argue that ethical values are
crucial to conducting much epidemiological research.
Focusing on epidemiological research on racial health
disparities, we will show that epidemiologists must
endorse particular public policy aims of the research,
i.e. to reduce the prevalence or incidence of particular
diseases, to eliminate disparities, or to improve health
care delivery. Thus, they must make value judgments.
They must also make value judgments in determining
how best these aims can be pursued. Values, then,
affect problem identification, as well as research
methodology. This case study will show that ethical
reasoning can promote epidemiological research that
is more scientifically sound and more effective in
addressing public policy aims. By making value
judgments explicit, we are more likely to pay atten-
tion to them and thus evaluate them in critical ways.
Finally, we discuss briefly the implications that this
has for scientific training. Scientific training should
prepare scientists to engage in ethical reasoning be-
cause it will not only make them more responsible
human beings, but also better scientists.
216
We do not intend to claim that ethical or social
values never lead to bias. Clearly, sometimes partic-
ular values have led scientists to interpret or ignore
data in ways that supported favored hypothesis. Of
course, it does not follow that because sometimes
value commitments lead to bad science we should
eliminate all such commitments. It does follow,
however, that some values might be inappropriate
when conducting scientific research. If so, careful
evaluation and attention to value judgments is even
more important.
Values and epidemiological research on health
disparities
Despite improvements in the overall health of U.S.
citizens, racial/ethnic minorities still receive a lower
quality of health services and have higher rates of
morbidity and mortality than whites [5]. For exam-
ple, the infant mortality rate in 2002 for African-
Americans, was more that twice as high as for whites
[5]. In 2001, the age-adjusted death rate for cancer
was 25.4 percent higher for African–Americans than
for white Americans [6]. Similarly, compared with
white adults, American Indians and Alaska Natives,
African–Americans, and Hispanics are more likely to
have diagnosed diabetes [7].
There is broad agreement about the importance of
undertaking research on health disparities so as to
reduce or eliminate them. However, there are at least
two main areas of disagreement as to how this aim
should be pursued. The first concerns the extent to
which resources to address this problem should be
devoted to research in population genetics. The sec-
ond concerns how race should be measured for pur-
poses of epidemiological studies. Making decisions
about these issues requires that scientists engage not
only on discussions of technical matters, but also in
ethical reasoning about the aims of the research, and
about which methods and research programs will best
promote those aims. That is, whatever decision is
reached, it rests on particular, often implicit, value
commitments. Our goal is to bring those values to the
forefront, so that they can be recognized and care-
fully evaluated.
Value judgments and decisions about research
programs
Until recently, the main hypothesis for the origins of
racial/ethnic health disparities emphasized social
factors such as socioeconomic disadvantages that
lead to unequal access to education, employment,
housing, and health services. Certainly, the idea that
genetics also played a role in such disparities is not
new. With the advent of the genetic revolution,
however, interest in using genetic science as a means
to both explain and eliminate racial/ethnic health
inequities has increased. Indeed, the purpose of sev-
eral NIH funded initiatives is to identify genetic
contributions to such disparities [8].
Although most researchers agree that social factors
contribute to health inequalities, some also argue that
it would be wrong to ignore the role of genetics [9,
10]. Many believe that understanding genetic varia-
tion across populations defined by race or genetic
ancestry will assist in the identification, tracking, and
investigation of genetic factors that underlie racial/
ethnic differences in the prevalence and severity of
diseases. It will also help us to determine differences
in responses to drugs and other treatments. More-
over, identification of genetic factors that contribute
to health disparities will help develop preventive and
therapeutic measures that address racial/ethnic health
inequalities [11, 12].
Other researchers argue that evidence that genes
have a significant influence on complex diseases is
scarce and that the distribution of polygenic pheno-
types does not suggest that race is a useful category
[13]. Others maintain that claims about medicines
having differences in safety or efficacy among racial/
ethnic groups are unsupported, [14] or that race
cannot offer the sensitivity and specificity necessary
to determine DNA sequence variation that can guide
preventive or curative measures [11].
Both sides of this debate assume, however, that if
genetic determinants were found, then genetic re-
search could assist us in reducing health disparities.
The debate, thus, is presented as a technical dis-
agreement about whether genetic differences under-
lying health disparities exist and whether we have the
technical capabilities to find them.
Nevertheless, resolving this debate requires
researchers to engage in ethical reasoning. If the aim
of epidemiological research on racial/ethnic health
disparities is to minimize or eliminate such dispari-
ties, scientists must make value judgments about
whether genetic research would be a good way to
achieve such end. To support or reject the use of
genetic research in the attempt to solve racial/ethnic
health inequalities is not just to make technical
judgments about whether such disparities can be
traced to genetic differences among racial/ethnic
groups. It is also to make explicit or implicit value
judgments about what the adequate means are to
achieve particular ethical and social goals of the re-
search.
Defending genetic research as an adequate means
to reduce racial/ethnic health disparities presupposes
that knowledge of genetic variation among racial/
ethnic groups could be translated into practices that
are likely to result in the eradication or diminution
of health inequalities [9–11, 15]. But such presup-
position, and thus the conclusion that genetic

research will be helpful in such a task, requires
scientists to evaluate political and social factors that
bear on the efficacy of genetic knowledge. Consider,
for example, hypertension, a condition that is twice
as likely to affect African Americans as whites [16,
17]. Some have argued that genetic factors increase
the propensity of black people of sub-Saharan
African descent to develop high blood pressure [18].
Others have indicated that such a genetic compo-
nent can be found in the physiology of salt sensi-
tivity [19, 20].
In what way would such knowledge contribute to
reducing racial/ethnic health disparities in hyper-
tension? One answer is that knowledge of genetic
variants will allow us to advance public health
approaches. Measures such as promoting weight
loss, reduction of dietary sodium, adequate intake of
fresh fruits and vegetables, and increased physical
activity all can contribute to the prevention of
hypertension [21]. Or it might be that knowledge of
genetic variants could be particularly valuable in
counseling at-risk groups more effectively. Doctors
could inform African–Americans that they are at
increased risk for hypertension by virtue of genetic
factors in addition to social factors. Also, once we
have knowledge of particular polymorphisms that
contribute to the risk of hypertension, for example,
this could be used to develop new drugs tailored to
them.
But the extent to which genetic research can help
reduce health inequalities depends in part on the
social context in which these strategies are
employed. For example, if the recommendations
likely to result from genetic knowledge are already
part of standard medical practice, then they might
do little to contribute to the goal of reducing or
eliminating health disparities. Similarly, whether the
development of new drugs resulting from genetic
research can help address racial health disparities
depends, at least in significant part, on whether
minority groups are likely to be able to afford
expensive drugs. If targeted populations cannot
afford genetically tailored medicine, then such drugs
will again do little to remedy health inequalities.
Deciding whether this would be the case requires
making value judgments about our social and
political context.
Similarly, value judgments are also relevant to
determining the particular health inequalities that
must be the subject of research. Such inequalities
might be the result of a variety of factors such as
genetic differences, differential access to health care,
or racial oppression. Defending genetic research as
key to diminishing health inequalities presupposes
that all such inequalities are equally deserving of our
attention or that those resulting from genetic differ-
ences are more important than other inequalities.
However, it might be that there is something partic-
ularly problematic about health inequalities that stem
217
from unjust racial discrimination as opposed to those
that might be the result of genetic factors [22].1 If this
is so, even if genetic research can be successful in
addressing health disparities, researchers will need to
judge whether such research is the best way to ad-
dress the kinds of disparities that are most important
to address.
If our arguments are correct, whether epidemiolo-
gists decide to consider or disregard the social con-
ditions likely to obtain when conducting
epidemiological research is to make value judgments,
i.e., that researchers ought or ought not pay attention
to such context, that using resources for investiga-
tions that would lend support to recommendations
already encouraged is good or bad, or that to conduct
research that will lead to medications unlikely to be
accessible to relevant populations is problematic or
acceptable.2
Certainly, in many situations the social or political
factors that affect the success of a research goal might
be uncertain. But this only means that such uncer-
tainty needs to be taken into account when making
value judgments. And of course, judgments that
might be perfectly appropriate in a situation of
uncertainty might be incorrect in one where we have
the relevant knowledge. In any case, value judgments
cannot be avoided when conducting research on
radical/ethnic disparities.
Still, genetic epidemiologists might argue that ge-
netic research should be prioritized not because of its
present value to achieve our goal, but because it has
the potential to generate cures that will be effective in
diminishing health disparities in the long term. Thus
attention to the current social context is irrelevant. Of
course, determining whether genetic research will be
able to eliminate health disparities in the future re-
quires empirical research. Yet, justifying such
empirical research would still require making value
judgments. For instance, epidemiologists must judge
that efforts directed to greater future outcomes are
better that those aimed at present amelioration.
1
We recognize that focusing on health disparities that are the
result of unjust racial discrimination may be more of a concern for
epidemiological research conducted in the U.S.A., or other coun-
tries where there is a long and significant history of racial
oppression. This may become a more prevalent concern for
European epidemiology due to immigration. Regardless, our point
is that whether epidemiological researchers on health disparities
focus on race, economic factors, or genetics depends on making
value judgments about how the research should be best focused to
promote the ethical and social aims of the research.
2
Notice that we are not conflating ethical value judgments with
judgments about social, political, or economic features of the world
in which epidemiological research is conducted. In other words, we
are not trying to reduce all social sciences to ethics. We recognize
that there are a host of different judgments that may be relevant to
conducting epidemiological research. Our claim is that scientists
must make ethical value judgments in deciding whether to regard
or disregard particular features of the social context so as to
determine how best to engage in epidemiological research that aims
to eliminate social health disparities.
218
In response to our arguments that epidemiologists
must make value judgments in order to justify
research programs, some might object that our
analysis conflates the scientific or epistemic aims of
epidemiological research with the public policy aims
of the research or with particular interventions. One
might argue that the scientific aim of epidemiological
research is simply to determine whether there are
genetic variants that are responsible for racial/ethnic
health disparities. The aim is to produce scientific
knowledge. This can be distinguished from the public
policy aims of such research, such as the aim to
reduce or eliminate health disparities, and from spe-
cific interventions, such as recommending behavioral
changes or developing new drugs. Presumably, deci-
sions about how best to pursue social and political
aims and interventions are best left to policymakers,
while scientists should focus on determining the
existence and causes of health disparities.
This objection, however, is problematic because it
begs the very question at stake. It presupposes that
values are irrelevant to the epistemic goals of the
research. This is certainly a common view, but
nonetheless one that we are rejecting in this paper.
The aim of research on health disparities is not just to
accurately describe health differences or determine
their cause, but to do so in a way that will be useful to
making predictions, preventing greater disparities,
and improving human health. As we have tried to
show, the scientific aims of research on health dis-
parities i.e. why African–Americans have higher
incidences of asthma than Caucasians, are insepara-
ble from its social goal, i.e. to eliminate such dis-
parities. At the same time this social goal also guides
decisions about what interventions would best
accomplish the goal. Such interventions however, i.e.
development of new drugs, better access to health
care, social policies that eliminate racial discrimina-
tion, must be grounded on particular research pro-
jects. For example, it would be odd to argue that a
policy attempting to promote affirmative action as a
way to reduce racial discrimination is grounded on
the results of genetic research directed to determine
whether African–American at a higher risk for lung
cancer than Caucasians. But if this is the case,
then we must use value judgments to decide what
type of research to pursue, i.e., whether we will
investigate genetic factors, economic aspects, or
unjust racial practices. And, as we have argued, each
of these possibilities is grounded on particular value
judgments.
Furthermore, even if one agreed that genetic epi-
demiologistsÕ task is simply to produce knowledge,
this also involves value judgments. For instance, sci-
entists must judge that knowledge is intrinsically
good or that we ought to use resources to produce
knowledge whether or not it is useful.
Although we have focused on value judgments that
genetic epidemiologists must make in pursuing their
research in health disparities, we do not mean that
only those defending this type of investigation make
value judgments. Decisions to pursue or prioritize
research on social determinants would also involve
making similar kinds of value judgments (i.e., judg-
ments about what the social aims of the research are
and whether the examination of certain social factors
would best promote those aims). Often such values go
unacknowledged. This is so, in part, because of the
common belief that value judgments have no place in
good science. But the fact that scientists lack training
to recognize and scrutinize them is also likely to
contribute to this problem.
Value judgments and measuring ‘‘race’’ in
epidemiological studies
In addition to making value judgments about which
research programs will be likely to promote the aims
of research on racial/ethnic health disparities, inves-
tigators must also make ethical value judgments
related to data collection decisions. In particular,
they must decide how race should be measured in
such studies [23].
Disagreements about race as a category in epide-
miological studies have focused on whether we are
measuring a characteristic with biological meaning or
a social construction [24, 25], whether race is a useful
category in biomedical research, and on questions
about how race should be categorized [26, 27]. In all
these instances, however, problems are usually seen
as technical not as ethical issues. But decisions about
how to best measure race depend on what we want
our racial categories to do. Hence, such decisions
require more than simply technical discussion; they
require researchers to make value judgments.
Health agencies have measured race in different
ways. Prior to 1980, the National Center of Health
Statistics (NCHS) classified a person as white if and
only if both parents were white [28]. After 1980, the
NCHS began assigning race on the basis of the bio-
logical motherÕs race alone. The National Census
Bureau has allowed individuals to self-designate their
race since the 1960 census. Beginning in 2000, censusÕ
respondents were given the option of self-designate
one or more race categories to indicate their racial
identities [29]. During the last decade, dissatisfaction
with self-identification has resulted in increased
interest in employing ancestry-informative markers
and other gene-only approaches. The question is,
which method or standard for determining race is the
best one? How should epidemiologists assign indi-
viduals to particular racial categories? Would it be
better to eliminate the concept of race?
Answers to these questions depend, again, on the
aims of the research. They rest on what we want the
category of race to measure in epidemiological stud-
ies [30]. As discussed above, a possible aim of health
disparity research might be to detect and reduce those

that are the result of unjust discrimination. That is,
epidemiological researchers can develop tools that
will assist us in identifying particular factors, in this
case unjust discrimination, that contribute to racial
health inequalities. The identification of such factors
can then be used to develop interventions that could
prevent disease, promote health, and provide appro-
priate medical care. These interventions presumably
will contribute to our goal of reduction of racial/
ethnic health disparities. This aim can only be
achieved, however, if we have a definition of race that
successfully identifies who is likely to be subjected to
racial discrimination and who is not. Which standard
for measuring race best tracks how racial categories
operate in racial discrimination? This is, of course, an
empirical question. But, conducting such work will
require scientists to make value judgments about
which behaviors, states of affairs, and material con-
ditions constitute unjust racial discrimination.
Similarly, if the aim of epidemiological research on
health disparities is to eliminate those caused by un-
just racial discrimination, we need a way of measur-
ing race that allows us to monitor and track
improvements or reductions in such inequalities. This
might be an argument in support of using older ways
of measuring race. Maintaining earlier classifications
will allow for data comparison.
If we are correct about the need to take into account
the aims of our research in order to determine how best
to measure race, then it follows that the concept of race
in epidemiological studies requires making value
judgments. Indeed, the goal of identifying health dif-
ferences caused by unjust racial discrimination, for
example, so that we can eliminate them and also
measure progress in reducing unjust racial discrimi-
nation presupposes ethical and political commitments.
It is these commitments that help us determine what
we want the concept of race to do for us.
Epidemiologists might object that value judgments
can still be avoided if we stop using value-laden
concepts like race altogether [31, 32]. Instead of
worrying about how to use the concept of race, epi-
demiologists should focus on other, presumably less
value-laden factors such as genetic markers, drug
metabolism, disease incidence, socioeconomic status,
education, or exposure to environmental hazards
[33]. Researchers could then have an accurate
understanding of disease risks and morbidity and
mortality rates on the basis of factors that do not rely
on the concept of race or on any value judgments
about racial discrimination.
This objection presents several problems. First, it is
not clear that the concept of race can be eliminated as
a significant category in epidemiological research.
Even when controlling for other factors such as ac-
cess, socioeconomic status, and education, there are
still racial differences in health outcomes [34, 35].
Second, the decision to eliminate race as category
in studying health disparities is itself grounded on
219
value judgments. Indeed the pursuit of genetic re-
search on health inequalities, for instance, that
explicitly endorses a methodology in which self-as-
cribed racial identity is replaced by genetic markers,
makes the value judgment that the aim of epidemio-
logical studies is not to eliminate health disparities
caused by unjust racial discrimination. Similarly, a
methodological choice to pay attention exclusively to
factors such as socioeconomic status, personal pref-
erences, or exposure to environmental hazards pre-
supposes that it is not important to understand how
unjust racial discrimination contributes to health
inequalities beyond such factors. Whether these
assumptions are correct is not the topic of this paper.
Our point is that whether race is a useful category in
health disparities research depends on value judg-
ments related to the social aims of the research.
Implications for science education
Currently, epidemiological education does not in-
clude training in ethical reasoning. In fact, scientists
are discouraged from thinking about the ethical or
social values related to their research, fearing that it
will lead to bias. But if our arguments here are cor-
rect, epidemiologists often must consider and endorse
certain social or political aims of the research and
determine how their research can best help promote
those aims.
Again, we are not claiming that ethical and social
values never lead to bias. Sometimes, relying on
particular values is inappropriate or distorts inter-
pretation of data, leads scientists to disregard plau-
sible alternative explanations, or causes scientists to
endorse a theory that is not warranted by the evi-
dence. Giving an account of when values do or do not
lead bias in scientific research is beyond the scope of
this paper. We argue, however, that ethical values are
an intrinsic part of conducting epidemiological re-
search. They simply cannot be avoided. But if this is
so, we cannot assume that scientists should never
engage in ethical reasoning.
If this is right, then training in epidemiology should
include some training related to the ethical and social
dimensions of research. Scientists need to be able to
identify and evaluate the ethical values at stake in
their studies. Moreover, scientists must justify their
methodological decisions in relation to the relevant
ethical values when appropriate.
We do not presume that values are always clear or
unproblematic, that they do not conflict with each
other, or that there is not disagreement about what
values are better or worse. In fact, is it precisely be-
cause we believe that values might be better or worse,
or that they might conflict with other values that we
desire to endorse that we advocate the importance of
ethical reasoning in scientific training.
Notice also that we are not arguing that training in
ethical reasoning is good for epidemiologists because
220
this would make them more conscientious human
beings. Our point is that it will also make them better
scientists. If at least some epidemiological research
requires making ethical value judgments, then inves-
tigators trained in ethics would be better able to as-
sess such judgments. Moreover, they would be aware
of what is already an important part of their research.
Scientists would be able to evaluate how particular
values influence specific research goals and method-
ologies and attend to whether and how such values
influence the realization of desired goals. More
importantly, they would be able to do this con-
sciously and critically.
To disregard the importance of ethical training
would be problematic for several reasons. First, sci-
entistsÕ work would be affected. They, for instance,
might be unlikely to recognize when value judgments
lead to biases and when such inclusion is a necessary
element of their research. Second, scientistÕs respon-
sibilities toward society might be unfulfilled. For
example, given that science is funded primarily
through public money, scientist ought to make
judgments about how best to use scarce resources.
Ethical training will assist them in evaluating such
judgments. Third, inattention to ethical education in
science reinforces the incorrect idea that scientists
need not be concerned with such issues [36]. Our case
study shows that value judgments can be an intrinsic
part of scientific research. Hence, scientists should
not present their results as if they were value-neutral
when, in fact, they are not. This would prevent a
thorough evaluation of scientific research. Good sci-
ence requires careful attention to the evidence, ade-
quate research protocols, and suitable questions. But
as necessary as all these factors are, they are not
always sufficient. For some type of research at least,
ethical reasoning is also essential.
Acknowledgements
We would like to thank Malia Fullerton for helpful
comments on earlier versions of this manuscript.
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Address for correspondence: Inmaculada de Melo-Martı́n , Division
of Medical Ethics, Weill Medical College of Cornell University, 411
E. 69th Street, New York, NY, 10021, USA
Phone: +212-746-1268
E-mail: imd2001@med.cornell.edu
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