How Should Clinicians Respond to Race-Based Algorithms as Sources of Iatrogenic Harm?

Abstract

Some clinical algorithms use race as an epidemiological shorthand to "correct" for health determinants that are clinically influential but also variable because they are historical, social, cultural, or economic in origin. Such "correction factors" are both clinically and ethically relevant when their use reinforces racial essentialism and exacerbates racial health inequity. This commentary on a case in which the original vaginal birth after cesarean calculator is used argues that this and similar racebased algorithms should be considered sources of iatrogenic harm by undermining decision sharing in patient-clinician relationships and Black birthing peoples' rights to self-determination.The American Medical Association designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ available through the AMA Ed Hub TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity. CaseDr OB is a resident physician in a high-volume obstetrics unit at a county hospital serving predominantly Black and urban Indigenous community members. Like other resident physicians, Dr OB often uses a mobile phone application to calculate, via algorithm, vaginal birth risk for birthing people who have delivered a prior child via cesarean section (C-section). 1 This vaginal birth after cesarean (VBAC) calculator has 2 race-based correction factors. 1 Scores yielded by the calculator are used to inform clinical management decisions-specifically, about which delivery options to offer patients in the unit-and to motivate standard of care. For individuals who have delivered by C-section before, the score is clinically and ethically important, since vaginal delivery complication risk for a person who has had a C-section is lower than C-section delivery complication risk for a person who has had a C-section. Strangely, though, Dr OB notices that most patients in the unit who have had a C-section are not offered an option to attempt labor and vaginal delivery.Dr OB enters a patient's race as White instead of Black a few times and notices score changes substantial enough to influence whether a patient who has had a C-section will be offered an option to try labor and vaginal delivery. Dr OB wonders about the validity of

Reexamining the use of race in medical algorithms: the maternal health calculator debate

“…The subsequent racial discrimination controversy surrounding the VBAC calculator prompted a reevaluation, leading Grobman and colleagues to revise the tool, replacing race/ethnicity with medical history components such as hypertension ( 5 ). This incident has sparked broader discourse on the critical need to reassess the role of race in clinical algorithms and to acknowledge the potential biases that arise from its misuse ( 31 , 36 ).…”

“…Nonetheless, only a few systematic solutions are proposed apart from the slow progress of undoing race corrections one at a time. Kane et al ( 36 ) proposed that clinicians and researchers use structurally just algorithms prioritizing social drivers of inequities such as insurance status, education, and economics. This alternative approach emphasizes structural justice by analyzing the root causes and working collaboratively with advocates and communities to address societal-level circumstances contributing to disparities such as those noted in maternal and child mortality.…”