The Science of Race and Pain

If you prick us with a pin, do we not bleed? If you tickle us, do we not laugh? If you poison us, do we not die?  —Shylock of Venice

When stepping into my neighborhood coffee shop, casually wielding a paper by Hoffman et al. (2016), the barista glanced at the title “Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites” and promptly pronounced it racist, presumably referring to the research findings and not the article per se. The title, it seems, had the desired effect, but do the findings support it?

Hoffman et al. begin by stating that “Black Americans are systematically undertreated for pain relative to white Americans,” and that “this racial bias is related to false beliefs about biological differences between blacks and whites (e.g., 'Black people’s skin is thicker than white people’s skin').” They find that White “participants who more strongly endorsed false beliefs about biological differences reported lower pain ratings for a black (vs. white) target” (p. 4296).

The context for this research is a set of earlier findings showing that African Americans are prescribed less pain medication for both moderate and severe pain than are Whites (e.g., Mills et al., 2011), yet it remains unclear to what extent this racial differential is a matter of an undertreatment (oligoanalgesia) of Blacks or an overtreatment of Whites. The authors cautiously note that both types of error may be involved. The difficulty here lies in the absence of a clear objective standard for the right treatment level. The authors also note that “racial bias in perceptions of pain (and possibly treatment) does not appear to be borne out of racist attitudes. In other words, it is likely not the result of racist individuals acting in racist ways,” (p. 4297) an observation that further complicates the interpretation of their results.

The first study involved 92 White participants, without medical training, judging the truth vs. falsity of 15 statements about biological differences between Blacks and Whites, 11 of which were in fact false, and judging the pain produced to a Black or a White person by each of 18 events (e.g., “I slam my hand in a car door”). The question then is whether false beliefs about race differences predict a race differential in perceived pain sensitivity. Indeed, those participants who were most likely to endorse false race beliefs rated the described accidents as more painful for Blacks than for Whites. Compared with the ratings made by low endorsers, there appeared to be an increase in the judged pain sensitivity of Whites and a decrease in the judged pain sensitivity of Blacks. In other words, it does not seem appropriate to take the judged pain sensitivity of Whites as judged by the high endorsers as the standard and attribute the entire difference between the judged pain sensitivity of Whites and the judged pain sensitivity of Blacks to a decrement or a decrease in the judgments of Blacks. There is no unambiguous evidence for anti-Black bias in these ratings, although they leave the possibility that there might be such a bias.

The interpretation of these results is complicated by the assessment of false beliefs. Of the 11 false statements, only 2 are face valid predictors of perceptions of pain sensitivity (“Blacks’ nerve endings are less sensitive than whites’,” and “Blacks’ skin is thicker than whites.”). The other false statements are neutral or favor Blacks (e.g., “Blacks have stronger immune systems than whites”). Indeed, a high rate of endorsement of these statements might be interpreted as a pro-Black bias. The authors aggregate over these statements, suggesting that the bias of accepting false biological beliefs as predictors or differential perceptions of pain sensitivity, when potentially the effect is driven only by two topically related items. Second, the authors ignore responses to the true statements (e.g., “Whites are less likely to have strokes than blacks”). This is a critical omission for it might be the case that the primary finding – perceiving Blacks as less pain sensitive than Whites, given other biologically differential beliefs – is simply a matter of endorsing differential race beliefs regardless of their accuracy. Given the authors’ narrative, one might ask for a test of the hypothesis that the degree to which Whites’ preferentially endorse false race beliefs over true ones predicts the difference in their judgments of pain sensitivity. The probability of such a hypothesis to be supported by the data appears to be low a priori. But I could be wrong; so why not test it?

The second study, replicating the design of the first, involved 222 medical students and residents. The findings replicated, sort of. Although high believers (in false and presumably true race differences) judged the pain sensitivity of Blacks to be lower than the pain sensitivity of Whites, the reverse was the case for low believers. The shape of this interaction effect was such that high and low believers did not differ in their ratings of Blacks, but did differ in their ratings of Whites, which, on the face of it, contradicts the theory that high believers are uniquely biased against Blacks. Incidentally, the proportion of high believers was lower in this study (12%) than in the first (50%), which corroborates the suspicion that the effect is not driven uniquely by false beliefs but more generally by gullibility (Krueger, Vogrincic-Haselbacher & Evans, 2019).

The authors also asked participants to recommend treatment, and they report that high believers were more likely to recommend ‘accurate’ treatment for Whites than for Blacks, while there was no difference for low believers. Notice the slippage from talking about the quantity and amount of prescribed medication, and acknowledging the possibility of both over- and undermedication, to flatly referring to accurate recommendations. The authors do not reveal what they mean by "accurate," neither in the main text nor in the supplemental materials, leaving the reader to wonder whether they equate stronger medicine with the correct choice. If this were so, we’d have evidence for race bias among the researchers instead of the subjects. This may seem like a strong suspicion to raise but ask yourself how research subjects would be evaluated if they declared the responses of or for Whites as a normative standard and treated any departure from this standard for a different racial group as ‘an effect’ or as a ‘fact of interest.’ Such a perspective is called othering in the linguistically inventive humanities (Grove & Zwi, 2006), and a default bias in the social psychology of racism, sexism, and other areas of intergroup relations (Devos & Banaji, 2005).

I have studied social categorization, stereotyping, and prejudice for over 30 years, and I am going out on a limb here. It is perfectly clear to me, as it is to most sentient Americans, that Anti-Black racism has been attenuated, but it has not been overcome. Yet, the implicit mission of some of the social-psychological research seems to have crept into an unproductive and scientifically questionable niche. When evidence mounted in the 1960s that explicit prejudice among Whites against Blacks was diminishing, some researchers suspected that this change was, at least in part, a matter of changing norms about what was permissible to express, but not a matter of change in deep-seated perceptions and feelings. These researchers began to look for new, creative, and sensitive ways of measuring prejudice. These efforts yielded impressive advances in unobtrusive and non-reactive measurement as well as theory and measurement of implicit cognition. This is the yin. The yang is that these new measurement instruments have encouraged an ever more relentless quest to suss out bias. The article by Hoffman and colleagues appears to fall into this tradition, leading the reader down the path to assume that physicians and others dehumanize Blacks. The attribution of sensitivity to pain is highly laden with assumptions about a shared humanity. Any reduction in this attribution smacks of empathy gaps and ultimately of cruelty, and that is hostile racism at its worst.

Scientists remain called upon to evaluate the data as comprehensively and impartially as possible. Let not the master narrative dictate the conclusions.

It is always well to read the full narrative and ponder its arc and implications. When Shylock lectures Salarino on the common humanity of Christians and Jews, he is setting the stage for his defense of revenge. He observes that Christians will seek revenge when being wronged; and so will Jews, following the example of those who are so similar to them in so many ways.

Note. The original title of this essay was African Pain. The editors changed it, perhaps they because thought it might be willfully misunderstood.