SECTION TWO: THE PRUDENTIAL ARGUMENT FOR PROFESSIONAL DIVERSITY

At this point, our argument takes a rather different direction. We contend that (ethics aside) a profession that is more diverse in its membership will be more excellent in the execution of its functional tasks than one that is not diverse. For purposes of clarification, we will term functional excellence, the prudential argument. Our prudential argument has two parts: a) the matching argument, and b) the social evolution argument. These will be addressed in order.

The Matching Argument It is generally agreed that the functional practice of medicine requires sympathy (sometimes called empathy) and care. These terms are understood as indicating both an emotional and an intellectual connection with the patient. Thus, a physician who cannot connect with her or his patient on an emotional and intellectual level in the sense of understanding the patient via both dimensions will be a functionally deficient practitioner. For example, if a physician fails to recognize ways that a patient emotively communicates to her, then she will be minus key facts about her patient. These key facts may be crucial in creating a diagnosis. Without them the physician is more prone to error. Making a wrong diagnosis is to be functionally deficient in the art and science of medicine. Thus, the physician who does not connect emotively with her patient puts herself in the position of rendering a deficient diagnosis (and all that follows from this: prognosis, treatment, etc.). Such a physician is functionally inferior to another physician who can connect with that patient.
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The same holds true with intellectual communication. Since much of rational human communication is in enthymemes, the physician is forced to fill in the gaps. But sometimes the enthymemes require cultural literacy and some common connectedness that may go beyond just being a fellow human-being living in the world. For example, some Latinas from Central America believe that breast cancer comes about as the result of loose living and so are reluctant to proceed with treatment even when a lump is detected. If the attending physician is not Latino/Latina or culturally competent in Central American culture, then he or she is liable to be ineffective as a provider of care. Likewise, an African-American physician who has sympathy/connection with black urban poor may better be able to communicate and render a professionally more accurate diagnosis so that the proper treatment might be undertaken.

Again, in another example (from The Holms Society), a 45-year-old African-American male with chronic back pain had an L4-5 laminectomy and fusion and still complains of significant pain. The patient is using low doses of codeine on a daily basis. You prescribed 25 mg of generic amitriptyline for the patient to take at bedtime and instructed the patient to increase to 50 mg after five days. The patient returns one month after you initiated the amitriptyline drug. He has not been taking it every night because he could not tolerate the side-effects. What is the next best step? This case involves knowledge of the physiology of African Americans. Since African Americans attain higher blood levels than whites when taking identical doses of tricyclics, the dose prescribed should take that into account—otherwise toxic side-effects may result. It is more likely that an African-American physician will be more sensitive to the physiology of his black patients than a white doctor and, thus, make a prescription for the appropriate dose of medication. This is another instance in which having a proportional diversity of physicians can increase professional excellence.
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Now, in principle, anyone sensitized to these crucial cues would be able to offer a professional level of care to the patient. However, such connectedness is difficult to come by. It is not taught in most medical schools—and is best possessed by people of similar racial/gender/ethnic backgrounds. What the authors see as the optimal solution to this problem is that the professions (here, orthopedic surgeons) possess proportional demographic representation. If this were the case, then these individuals would be there to help train the rest of their colleagues on the fine points of cultural literacy (necessary for proper communication between patient and doctor). They would be there—both to care directly, to consult with the direct caregiver, and to discuss common problems in clinical settings. If there were proportional representation in the field, and if these physicians were evenly distributed around the country (at least consistent with that population’s relative concentrations), then according to the preceding argu­ments, the African-American patients would receive better care and the functional practice of orthopedic medicine would be practiced at a higher level. (The same, obviously, holds true for other under-represented groups, such as Latino physicians, Native American physicians, and women physicians.)

Thus, since the demographics of the United States are heterogeneous with (for example) African Americans constituting 12% of the population, and since it has been argued that subpopulations are best served by there being a proportional diversity in the professional caregivers, it would seem logical that orthopedic surgeons (as well as all other professions) would become functionally more excellent by taking active steps to insure proportional diversity (see the last section of this essay for an outline of these steps).
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The Social Evolution Argument

Evolutionary theory in biology has proven to be a very useful theory. It has wide explanatory power and has acted to unite the field of biology. In fact, evolutionary theory has been so successful that beginning with the sociobiologists led by E.O. Wilson and Richard Dawkins, they have moved evolutionary biology into the social realm. This has led to a bifurcation between those such as Wilson and Dawkins, who want to assert that there is a biological basis to all behavior (biological determinism) and others, such as Eliot Sober and Richard Sloan Wilson, who wish to adapt biological theories into sociological models (though both are philosophers of biology). If one were to adapt models of biological evolution onto the social realm, then the same postulates that rule biology would apply to human society. The postulates that interest us are:

• There is racial/ethnic variation in a society (such as the United States)
• The environment of the United States (the infrastructure and the exostructure) is constantly in flux
• Populations that are robustly diverse will be survive changing environments better than those that are not
• Countries that do not empower their diverse populations are virtually the same as homogeneous populations

From these four principles, we can infer that homogeneous populations and those that are virtually the same as homogeneous populations, viz., those that do not empower their diverse subpopulations, will be functionally less fit for performing excellently in a diverse world. This is because each subpopu-lation can be described by a set of character traits. No trait is good or bad by itself but merely effective or not within a certain environment. For example, if there were a robust population that was heterogeneous and within the population there were individuals who were excellent at tracking several problems at the same time and quickly moving their attention from one task to the next, then these individuals (in an “information age” environment 1) will help the population succeed. In this event, the existence of quick-thinking, phrenetic individuals will be prized within the population.
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However, if we take these same individuals and pattern a new technological society (environment 2) in which quick decisions cease to be important but slow-thinking pondering of a single problem is the critical factor for success, then the population will need some slow-thinking individuals who can stay on a single problem for extended periods of time. The phrenetic individuals so prized in environment 1 will become losers in environment 2.

So is it “better” to be quick-thinking or to be slow thinking? The answer is that neither are per se better but only relatively better given certain environmental factors. This is why the most successful populations are those that will be the most diverse and welcome, honor, and support this diversity.

Yet, when we look at the reality of life in America (or virtually any other country we’ve heard of), it seems that the aim of public policy is to only allow diversity if it means to bring in more janitors, farm workers, or other underpaid “semislaves.” This servitude mentality is meant to preserve preference against the model of merit (discussed earlier). Under the model of social evolution, this is a prescription for social disintegration. Since it’s a given that social environments (as well as biomes) will change, unless the population has groomed a representative cross-section of its population to carry on its professions, these professions (arguably the backbone of society) may (probably) functionally degenerate under these new conditions, and the society will suffer.
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If this argument is correct, then all significant groups in the society must be represented within the professions. In the case study of this essay (African-American representation in orthopedic surgery), this means that for the functional good of the profession, drastic measures must be taken now. Otherwise, the future of the profession is doomed to unresponsive, decadent decline.