Ethical Considerations Regarding the Use of Race in Pulmonary Function Testing

Abstract

When Samuel Cartwright compared lung function in White vs enslaved Black people in the mid-19th century, the observed differences were used to support white supremacy through a biologic hierarchy of racial groups.1Braun L. Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics. University of Minnesota Press, 2014Crossref Google Scholar Although race is now understood as a social rather than biologic construct,2Flanagin A. Frey T. Christiansen S.L. AMA Manual of Style CommitteeUpdated guidance on the reporting of race and ethnicity in medical and science journals.JAMA. 2021; 326: 621-627Crossref PubMed Scopus (189) Google Scholar the idea that race is a variable relevant to differences in “normal” lung function still endures in the use of race-specific reference equations (RSEs) to interpret pulmonary function tests (PFTs). Although based on more recent data,3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar RSEs nonetheless run the risk of perpetuating racism that is inherent to the historic interpretation of PFTs beginning 2 centuries ago.For PFTs in particular and medicine more generally, the use of race in medical calculators has been increasingly scrutinized over concerns that doing so may contribute to racial bias in health care. As a result, the vaginal birth after cesarean and glomerular filtration rate calculators, both of which previously included terms for race, have been reevaluated and now use race-free equations.4Inker L.A. Eneanya N.D. Coresh J. et al.New creatinine- and cystatin C–based equations to estimate GFR without race.N Engl J Med. 2021; 385: 1737-1749Crossref PubMed Scopus (240) Google Scholar,5Grobman W.A. Sandoval G. Rice M.M. et al.Prediction of vaginal birth after cesarean delivery in term gestations: a calculator without race and ethnicity.Am J Obstet Gynecol. 2021; 225: 664.e1-664.e7Abstract Full Text Full Text PDF Scopus (36) Google Scholar However, PFTs continue to rely on RSEs although these are currently being reevaluated.3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar,6Bhakta N.R. Kaminsky D.A. Bime C. et al.Addressing race in pulmonary function testing by aligning intent and evidence with practice and perception.Chest. 2022; 161: 288-297Abstract Full Text Full Text PDF PubMed Google Scholar,7Stanojevic S. Kaminsky D.A. Miller M. et al.ERS/ATS technical standard on interpretive strategies for routine lung function tests.Eur Respir J. 2021; 2101499Google ScholarMuch of the examination of PFT RSEs to date has focused primarily on scientific concerns related to patient factors that predict normal lung function. However, a comprehensive evaluation also necessitates the incorporation of ethical considerations to aid in the identification of relevant harms and benefits and to contextualize scientific facts. Accordingly, we describe salient ethical considerations that are associated with PFT RSEs in four domains: (1) accurate categorization of respiratory disease; (2) potential physical, social, and economic harms; (3) elucidation of observed racial differences in lung function; and (4) elimination or continuation of the use of race-specific equations. Although we concentrate on issues of direct relevance to patients in the United States, these considerations should apply generally in other settings, despite the sometimes marked differences of race, culture, society, and health care delivery.Accurate Categorization of Respiratory DiseaseConsistent with the ethical obligation of beneficence, accurate interpretation of PFTs is necessary to identify correctly the presence and severity of respiratory disease and to minimize risks of either over- or under-diagnoses. Moreover, the use of inaccurate equations may exacerbate the disproportionate burdens of misdiagnoses, disease, and medical discrimination already faced by racialized groups.A prominent rationale for the use of PFT RSEs is that lung function varies within healthy populations according to several factors, including race.3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar Mathematically, RSEs improve PFT precision,3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar but it is unclear whether they more accurately determine normal vs abnormal lung function. Although factors such as height have a clear physiologic relationship to lung function (ie, height is correlated with lung size), race does not. If race acts as a surrogate for other causal factors (eg, health or environmental differences), which are associated independently with worse respiratory function, then those causal factors should be used in lieu of race.Practical difficulties related to the implementation of RSEs also pose threats to accuracy. Although race ought to be patient reported, clinicians or staff could incorrectly assume race from a patient’s appearance and therefore use the wrong RSE. Furthermore, as a nonstatic social construct, racial categories evolve over time and are geographically heterogeneous. Even if accurate now in some areas, RSEs are likely to lose accuracy over time.Potential Physical, Social, and Economic HarmsIf RSEs are indeed more accurate than race-free equations, any incremental benefit to accuracy should outweigh and minimize the physical, economic, and social harms that are associated with RSEs to justify their use.Physical harms to Black and Asian people may result from RSEs because of systemic underdiagnosis and undertreatment. RSEs are based on the observation that healthy Black and Asian people have lower average lung function than White people.3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar Consequently, expected lung function values are stratified by race, with lower expected values for Black and Asian people than White people.3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar This means that the same measured value will be interpreted as a higher percent predicted value for Black and Asian individuals compared with otherwise matched White individuals. Although international standards caution against the use of strict PFT cutoffs to define disease,7Stanojevic S. Kaminsky D.A. Miller M. et al.ERS/ATS technical standard on interpretive strategies for routine lung function tests.Eur Respir J. 2021; 2101499Google Scholar the higher percent predicted values from RSEs nonetheless could obscure the identification of Black patients with respiratory impairment. Clinicians may dismiss symptoms if PFTs inappropriately appear “normal”; thus, RSEs may lead to delayed diagnosis and treatment, which could in turn result in higher morbidity and mortality rates among Black and Asian populations. RSEs may also reify the incorrect belief among some clinicians that race is a biologic rather than social construct, thereby promoting implicit bias and undertreatment of Black and Asian patients1Braun L. Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics. University of Minnesota Press, 2014Crossref Google Scholar and perpetuating existing health disparities.If RSEs result in adverse health consequences, there may be consequent economic harms from higher health care costs and loss of wages. Additionally, higher RSE percent-predicted lung function among Black and Asian patients means they are less likely to qualify for disability in the United States. Although any system that bases disability assessment on a reference value may be flawed and unfair inherently, the current system has already been used to limit disability compensation to Black patients.1Braun L. Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics. University of Minnesota Press, 2014Crossref Google Scholar Together, these increased costs for Black and Asian patients could exacerbate existing economic disparities, which is ethically unjust.RSEs may also foster social harms. Because RSEs may suggest that normal lung function is lower in Black people compared with White people, they implicitly support a notion that Black lungs are inferior, which threatens to perpetuate centuries of social harm to Black people in the United States. Furthermore, if RSEs systematically bias care to the disadvantage of Black and Asian patients, they may perpetuate systemic racism, which would be a profound injustice.Conversely, race-free equations could result in harms. Certain occupations and medical therapies (including some surgeries and chemotherapies) require PFT values above a percent predicted cut-off. For example, a Black or Asian firefighter could lose eligibility to work if their percent predicted PFT values artificially fall because of the use of race-free equations, despite no change to their underlying lung function. Although that individual is perhaps protected from risk of occupational harm, there is nonetheless economic harm from loss of eligibility to work. Additionally, not all potential race-free approaches are equal, and the application of a single equation that was derived in a White population to all patients as a universal approach may carry similar social risks, as described earlier, by implicitly normalizing White lung function.Elucidating Observed Racial Differences in Lung FunctionObserved racial variation in lung function warrants further study to determine factors that contribute to these differences such as socioeconomic status, diet, pollution exposure, and decreased access to health care. However, investigations of racial differences must carefully avoid perpetuating race-based medicine and must not be used to promote the concept of innate biologic differences between racial groups. For example, the use of seated height and ancestry may improve reference equations6Bhakta N.R. Kaminsky D.A. Bime C. et al.Addressing race in pulmonary function testing by aligning intent and evidence with practice and perception.Chest. 2022; 161: 288-297Abstract Full Text Full Text PDF PubMed Google Scholar; however, studies of these factors should carefully avoid the conclusion that they demonstrate a biologic basis to race. Indeed, seated height actually could be a marker of socioeconomic status, given the dependence of childhood growth on nutritional and environmental factors. Genetic ancestry may have potential to enhance accuracy but may be problematic because of the incorrect implication of a genetic basis to race (when ancestry itself may be a surrogate for socioeconomic status, shared social histories, or environmental factors).8Lewis A.C.F. Molina S.J. Appelbaum P.S. et al.Getting genetic ancestry right for science and society.Science. 2022; 376: 250-252Crossref PubMed Scopus (10) Google ScholarEliminating or Continuing to Use Race-Specific EquationsAs detailed in Table 1, there are multiple ethical and practical challenges related to either elimination or continuation of the use of PFT RSEs. If RSEs are eliminated in favor of race-free equation(s), an abrupt change in PFT percent predicted values may harm patients if clinicians overreact (eg, ordering diagnostic tests or starting therapy for a presumed, but not actual, decline in lung function) or by the alteration of patients’ eligibility for specific jobs. In addition, Black and Asian patients could gain waitlist priority and disability benefits, while the priority and benefits now afforded to White patients would become equitable rather than advantaged. If RSEs are retained, challenges will include the promotion of transparency and autonomy by informing patients about the use of race and combatting implicit bias compounded by the use of RSEs.Table 1Practical and Ethical Challenges Related to the Continuation or Elimination of the Use of Race in Pulmonary Function Test Reference Equations and Possible SolutionsChallenges and Proposed Solutions for CONTINUING to Use Race-Specific EquationsChallenges and Proposed Solutions for ELIMINATING Race-Specific Equations1.Promote transparency and autonomy.1.Minimize risk of harm from over-reaction/over-treatment in response to an apparent artificial change in PFT interpretations.•Inform patients about how race is used in interpreting PFTs and the rationale for asking about it.•Assess clinician understanding and provide education.•Consider showing both race-specific and race-free percent predicted values.•Emphasize tracking disease severity with absolute, rather then percent predicted, values.2.Ensure clinicians' awareness of how to interpret RSEs and to combat implicit bias.2.Promote quality care and justice in the recalculation of past PFTs.•Assess clinician understanding and provide education.•Determine the extent to which past PFTs should be recalculated and apply this standard to patient equitably.3.Combat biased inclusion in research trials that use percent predicted PFT inclusion criteria.3.Ensure justice with changes to transplant waiting lists and disability benefits systems (Black and Asian patients could gain waitlist priority and disability benefits; White patients' waitlist priority and disability benefits could become equitable rather than advantaged).•Consider the use of measured lung function rather than percent predicted estimates.•Engage in multi-stakeholder discussions that address anticipated changes.…•Educate patients in advance if they will face loss or gain of benefits.…•Reevaluate the current systems’ reliance on PFTs for the determination of eligibility.4.Promote equitable public health.4.Ensure justice with changes to eligibility for certain jobs (eg, firefighting, military), chemotherapies, and surgeries (Black and Asian patients could lose eligibility).•Study underlying determinants of lung health rather than assuming variation in lung function is normal biology.•Engage in multi-stakeholder discussion by addressing anticipated changes.…•Reevaluate the current systems’ reliance on PFTs for the determination of eligibility.5.Promote quality care and justice via accurate reference equations (under the assumption that RSEs are necessary for accuracy).5.Minimize physical, economic, social harms.•Include data from diverse populations, particularly for lung volumes and diffusing capacity reference equations.•Thoroughly evaluate different proposed race-free equations.PFT = pulmonary function test; RSE = race-specific reference equation Open table in a new tab ConclusionAlthough the anticipated benefits of continuing RSEs to heighten precision of PFTs are quantifiable, many of the physical, social, and economic harms of doing so are not. Nonetheless, they matter ethically. Eliminating racism in medicine will involve multiple activities over the long term; however, there are concrete intentional steps that can be taken now to move closer to this goal such as the explicit inclusion of ethical considerations in ongoing deliberations that concern RSEs, their current use, and in any future transition to race-free equations. When Samuel Cartwright compared lung function in White vs enslaved Black people in the mid-19th century, the observed differences were used to support white supremacy through a biologic hierarchy of racial groups.1Braun L. Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics. University of Minnesota Press, 2014Crossref Google Scholar Although race is now understood as a social rather than biologic construct,2Flanagin A. Frey T. Christiansen S.L. AMA Manual of Style CommitteeUpdated guidance on the reporting of race and ethnicity in medical and science journals.JAMA. 2021; 326: 621-627Crossref PubMed Scopus (189) Google Scholar the idea that race is a variable relevant to differences in “normal” lung function still endures in the use of race-specific reference equations (RSEs) to interpret pulmonary function tests (PFTs). Although based on more recent data,3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar RSEs nonetheless run the risk of perpetuating racism that is inherent to the historic interpretation of PFTs beginning 2 centuries ago. For PFTs in particular and medicine more generally, the use of race in medical calculators has been increasingly scrutinized over concerns that doing so may contribute to racial bias in health care. As a result, the vaginal birth after cesarean and glomerular filtration rate calculators, both of which previously included terms for race, have been reevaluated and now use race-free equations.4Inker L.A. Eneanya N.D. Coresh J. et al.New creatinine- and cystatin C–based equations to estimate GFR without race.N Engl J Med. 2021; 385: 1737-1749Crossref PubMed Scopus (240) Google Scholar,5Grobman W.A. Sandoval G. Rice M.M. et al.Prediction of vaginal birth after cesarean delivery in term gestations: a calculator without race and ethnicity.Am J Obstet Gynecol. 2021; 225: 664.e1-664.e7Abstract Full Text Full Text PDF Scopus (36) Google Scholar However, PFTs continue to rely on RSEs although these are currently being reevaluated.3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar,6Bhakta N.R. Kaminsky D.A. Bime C. et al.Addressing race in pulmonary function testing by aligning intent and evidence with practice and perception.Chest. 2022; 161: 288-297Abstract Full Text Full Text PDF PubMed Google Scholar,7Stanojevic S. Kaminsky D.A. Miller M. et al.ERS/ATS technical standard on interpretive strategies for routine lung function tests.Eur Respir J. 2021; 2101499Google Scholar Much of the examination of PFT RSEs to date has focused primarily on scientific concerns related to patient factors that predict normal lung function. However, a comprehensive evaluation also necessitates the incorporation of ethical considerations to aid in the identification of relevant harms and benefits and to contextualize scientific facts. Accordingly, we describe salient ethical considerations that are associated with PFT RSEs in four domains: (1) accurate categorization of respiratory disease; (2) potential physical, social, and economic harms; (3) elucidation of observed racial differences in lung function; and (4) elimination or continuation of the use of race-specific equations. Although we concentrate on issues of direct relevance to patients in the United States, these considerations should apply generally in other settings, despite the sometimes marked differences of race, culture, society, and health care delivery. Accurate Categorization of Respiratory DiseaseConsistent with the ethical obligation of beneficence, accurate interpretation of PFTs is necessary to identify correctly the presence and severity of respiratory disease and to minimize risks of either over- or under-diagnoses. Moreover, the use of inaccurate equations may exacerbate the disproportionate burdens of misdiagnoses, disease, and medical discrimination already faced by racialized groups.A prominent rationale for the use of PFT RSEs is that lung function varies within healthy populations according to several factors, including race.3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar Mathematically, RSEs improve PFT precision,3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar but it is unclear whether they more accurately determine normal vs abnormal lung function. Although factors such as height have a clear physiologic relationship to lung function (ie, height is correlated with lung size), race does not. If race acts as a surrogate for other causal factors (eg, health or environmental differences), which are associated independently with worse respiratory function, then those causal factors should be used in lieu of race.Practical difficulties related to the implementation of RSEs also pose threats to accuracy. Although race ought to be patient reported, clinicians or staff could incorrectly assume race from a patient’s appearance and therefore use the wrong RSE. Furthermore, as a nonstatic social construct, racial categories evolve over time and are geographically heterogeneous. Even if accurate now in some areas, RSEs are likely to lose accuracy over time. Consistent with the ethical obligation of beneficence, accurate interpretation of PFTs is necessary to identify correctly the presence and severity of respiratory disease and to minimize risks of either over- or under-diagnoses. Moreover, the use of inaccurate equations may exacerbate the disproportionate burdens of misdiagnoses, disease, and medical discrimination already faced by racialized groups. A prominent rationale for the use of PFT RSEs is that lung function varies within healthy populations according to several factors, including race.3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar Mathematically, RSEs improve PFT precision,3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar but it is unclear whether they more accurately determine normal vs abnormal lung function. Although factors such as height have a clear physiologic relationship to lung function (ie, height is correlated with lung size), race does not. If race acts as a surrogate for other causal factors (eg, health or environmental differences), which are associated independently with worse respiratory function, then those causal factors should be used in lieu of race. Practical difficulties related to the implementation of RSEs also pose threats to accuracy. Although race ought to be patient reported, clinicians or staff could incorrectly assume race from a patient’s appearance and therefore use the wrong RSE. Furthermore, as a nonstatic social construct, racial categories evolve over time and are geographically heterogeneous. Even if accurate now in some areas, RSEs are likely to lose accuracy over time. Potential Physical, Social, and Economic HarmsIf RSEs are indeed more accurate than race-free equations, any incremental benefit to accuracy should outweigh and minimize the physical, economic, and social harms that are associated with RSEs to justify their use.Physical harms to Black and Asian people may result from RSEs because of systemic underdiagnosis and undertreatment. RSEs are based on the observation that healthy Black and Asian people have lower average lung function than White people.3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar Consequently, expected lung function values are stratified by race, with lower expected values for Black and Asian people than White people.3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar This means that the same measured value will be interpreted as a higher percent predicted value for Black and Asian individuals compared with otherwise matched White individuals. Although international standards caution against the use of strict PFT cutoffs to define disease,7Stanojevic S. Kaminsky D.A. Miller M. et al.ERS/ATS technical standard on interpretive strategies for routine lung function tests.Eur Respir J. 2021; 2101499Google Scholar the higher percent predicted values from RSEs nonetheless could obscure the identification of Black patients with respiratory impairment. Clinicians may dismiss symptoms if PFTs inappropriately appear “normal”; thus, RSEs may lead to delayed diagnosis and treatment, which could in turn result in higher morbidity and mortality rates among Black and Asian populations. RSEs may also reify the incorrect belief among some clinicians that race is a biologic rather than social construct, thereby promoting implicit bias and undertreatment of Black and Asian patients1Braun L. Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics. University of Minnesota Press, 2014Crossref Google Scholar and perpetuating existing health disparities.If RSEs result in adverse health consequences, there may be consequent economic harms from higher health care costs and loss of wages. Additionally, higher RSE percent-predicted lung function among Black and Asian patients means they are less likely to qualify for disability in the United States. Although any system that bases disability assessment on a reference value may be flawed and unfair inherently, the current system has already been used to limit disability compensation to Black patients.1Braun L. Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics. University of Minnesota Press, 2014Crossref Google Scholar Together, these increased costs for Black and Asian patients could exacerbate existing economic disparities, which is ethically unjust.RSEs may also foster social harms. Because RSEs may suggest that normal lung function is lower in Black people compared with White people, they implicitly support a notion that Black lungs are inferior, which threatens to perpetuate centuries of social harm to Black people in the United States. Furthermore, if RSEs systematically bias care to the disadvantage of Black and Asian patients, they may perpetuate systemic racism, which would be a profound injustice.Conversely, race-free equations could result in harms. Certain occupations and medical therapies (including some surgeries and chemotherapies) require PFT values above a percent predicted cut-off. For example, a Black or Asian firefighter could lose eligibility to work if their percent predicted PFT values artificially fall because of the use of race-free equations, despite no change to their underlying lung function. Although that individual is perhaps protected from risk of occupational harm, there is nonetheless economic harm from loss of eligibility to work. Additionally, not all potential race-free approaches are equal, and the application of a single equation that was derived in a White population to all patients as a universal approach may carry similar social risks, as described earlier, by implicitly normalizing White lung function. If RSEs are indeed more accurate than race-free equations, any incremental benefit to accuracy should outweigh and minimize the physical, economic, and social harms that are associated with RSEs to justify their use. Physical harms to Black and Asian people may result from RSEs because of systemic underdiagnosis and undertreatment. RSEs are based on the observation that healthy Black and Asian people have lower average lung function than White people.3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar Consequently, expected lung function values are stratified by race, with lower expected values for Black and Asian people than White people.3Quanjer P.H. Stanojevic S. Cole T.J. et al.Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations.Eur Respir J. 2012; 40: 1324-1343Crossref PubMed Scopus (3076) Google Scholar This means that the same measured value will be interpreted as a higher percent predicted value for Black and Asian individuals compared with otherwise matched White individuals. Although international standards caution against the use of strict PFT cutoffs to define disease,7Stanojevic S. Kaminsky D.A. Miller M. et al.ERS/ATS technical standard on interpretive strategies for routine lung function tests.Eur Respir J. 2021; 2101499Google Scholar the higher percent predicted values from RSEs nonetheless could obscure the identification of Black patients with respiratory impairment. Clinicians may dismiss symptoms if PFTs inappropriately appear “normal”; thus, RSEs may lead to delayed diagnosis and treatment, which could in turn result in higher morbidity and mortality rates among Black and Asian populations. RSEs may also reify the incorrect belief among some clinicians that race is a biologic rather than social construct, thereby promoting implicit bias and undertreatment of Black and Asian patients1Braun L. Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics. University of Minnesota Press, 2014Crossref Google Scholar and perpetuating existing health disparities. If RSEs result in adverse health consequences, there may be consequent economic harms from higher health care costs and loss of wages. Additionally, higher RSE percent-predicted lung function among Black and Asian patients means they are less likely to qualify for disability in the United States. Although any system that bases disability assessment on a reference value may be flawed and unfair inherently, the current system has already been used to limit disability compensation to Black patients.1Braun L. Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics. University of Minnesota Press, 2014Crossref Google Scholar Together, these increased costs for Black and Asian patients could exacerbate existing economic disparities, which is ethically unjust. RSEs may also foster social harms. Because RSEs may suggest that normal lung function is lower in Black people compared with White people, they implicitly support a notion that Black lungs are inferior, which threatens to perpetuate centuries of social harm to Black people in the United States. Furthermore, if RSEs systematically bias care to the disadvantage of Black and Asian patients, they may perpetuate systemic racism, which would be a profound injustice. Conversely, race-free equations could result in harms. Certain occupations and medical therapies (including some surgeries and chemotherapies) require PFT values above a percent predicted cut-off. For example, a Black or Asian firefighter could lose eligibility to work if their percent predicted PFT values artificially fall because of the use of race-free equations, despite no change to their underlying lung function. Although that individual is perhaps protected from risk of occupational harm, there is nonetheless economic harm from loss of eligibility to work. Additionally, not all potential race-free approaches are equal, and the application of a single equation that was derived in a White population to all patients as a universal approach may carry similar social risks, as described earlier, by implicitly normalizing White lung function. Elucidating Observed Racial Differences in Lung FunctionObserved racial variation in lung function warrants further study to determine factors that contribute to these differences such as socioeconomic status, diet, pollution exposure, and decreased access to health care. However, investigations of racial differences must carefully avoid perpetuating race-based medicine and must not be used to promote the concept of innate biologic differences between racial groups. For example, the use of seated height and ancestry may improve reference equations6Bhakta N.R. Kaminsky D.A. Bime C. et al.Addressing race in pulmonary function testing by aligning intent and evidence with practice and perception.Chest. 2022; 161: 288-297Abstract Full Text Full Text PDF PubMed Google Scholar; however, studies of these factors should carefully avoid the conclusion that they demonstrate a biologic basis to race. Indeed, seated height actually could be a marker of socioeconomic status, given the dependence of childhood growth on nutritional and environmental factors. Genetic ancestry may have potential to enhance accuracy but may be problematic because of the incorrect implication of a genetic basis to race (when ancestry itself may be a surrogate for socioeconomic status, shared social histories, or environmental factors).8Lewis A.C.F. Molina S.J. Appelbaum P.S. et al.Getting genetic ancestry right for science and society.Science. 2022; 376: 250-252Crossref PubMed Scopus (10) Google Scholar Observed racial variation in lung function warrants further study to determine factors that contribute to these differences such as socioeconomic status, diet, pollution exposure, and decreased access to health care. However, investigations of racial differences must carefully avoid perpetuating race-based medicine and must not be used to promote the concept of innate biologic differences between racial groups. For example, the use of seated height and ancestry may improve reference equations6Bhakta N.R. Kaminsky D.A. Bime C. et al.Addressing race in pulmonary function testing by aligning intent and evidence with practice and perception.Chest. 2022; 161: 288-297Abstract Full Text Full Text PDF PubMed Google Scholar; however, studies of these factors should carefully avoid the conclusion that they demonstrate a biologic basis to race. Indeed, seated height actually could be a marker of socioeconomic status, given the dependence of childhood growth on nutritional and environmental factors. Genetic ancestry may have potential to enhance accuracy but may be problematic because of the incorrect implication of a genetic basis to race (when ancestry itself may be a surrogate for socioeconomic status, shared social histories, or environmental factors).8Lewis A.C.F. Molina S.J. Appelbaum P.S. et al.Getting genetic ancestry right for science and society.Science. 2022; 376: 250-252Crossref PubMed Scopus (10) Google Scholar Eliminating or Continuing to Use Race-Specific EquationsAs detailed in Table 1, there are multiple ethical and practical challenges related to either elimination or continuation of the use of PFT RSEs. If RSEs are eliminated in favor of race-free equation(s), an abrupt change in PFT percent predicted values may harm patients if clinicians overreact (eg, ordering diagnostic tests or starting therapy for a presumed, but not actual, decline in lung function) or by the alteration of patients’ eligibility for specific jobs. In addition, Black and Asian patients could gain waitlist priority and disability benefits, while the priority and benefits now afforded to White patients would become equitable rather than advantaged. If RSEs are retained, challenges will include the promotion of transparency and autonomy by informing patients about the use of race and combatting implicit bias compounded by the use of RSEs.Table 1Practical and Ethical Challenges Related to the Continuation or Elimination of the Use of Race in Pulmonary Function Test Reference Equations and Possible SolutionsChallenges and Proposed Solutions for CONTINUING to Use Race-Specific EquationsChallenges and Proposed Solutions for ELIMINATING Race-Specific Equations1.Promote transparency and autonomy.1.Minimize risk of harm from over-reaction/over-treatment in response to an apparent artificial change in PFT interpretations.•Inform patients about how race is used in interpreting PFTs and the rationale for asking about it.•Assess clinician understanding and provide education.•Consider showing both race-specific and race-free percent predicted values.•Emphasize tracking disease severity with absolute, rather then percent predicted, values.2.Ensure clinicians' awareness of how to interpret RSEs and to combat implicit bias.2.Promote quality care and justice in the recalculation of past PFTs.•Assess clinician understanding and provide education.•Determine the extent to which past PFTs should be recalculated and apply this standard to patient equitably.3.Combat biased inclusion in research trials that use percent predicted PFT inclusion criteria.3.Ensure justice with changes to transplant waiting lists and disability benefits systems (Black and Asian patients could gain waitlist priority and disability benefits; White patients' waitlist priority and disability benefits could become equitable rather than advantaged).•Consider the use of measured lung function rather than percent predicted estimates.•Engage in multi-stakeholder discussions that address anticipated changes.…•Educate patients in advance if they will face loss or gain of benefits.…•Reevaluate the current systems’ reliance on PFTs for the determination of eligibility.4.Promote equitable public health.4.Ensure justice with changes to eligibility for certain jobs (eg, firefighting, military), chemotherapies, and surgeries (Black and Asian patients could lose eligibility).•Study underlying determinants of lung health rather than assuming variation in lung function is normal biology.•Engage in multi-stakeholder discussion by addressing anticipated changes.…•Reevaluate the current systems’ reliance on PFTs for the determination of eligibility.5.Promote quality care and justice via accurate reference equations (under the assumption that RSEs are necessary for accuracy).5.Minimize physical, economic, social harms.•Include data from diverse populations, particularly for lung volumes and diffusing capacity reference equations.•Thoroughly evaluate different proposed race-free equations.PFT = pulmonary function test; RSE = race-specific reference equation Open table in a new tab As detailed in Table 1, there are multiple ethical and practical challenges related to either elimination or continuation of the use of PFT RSEs. If RSEs are eliminated in favor of race-free equation(s), an abrupt change in PFT percent predicted values may harm patients if clinicians overreact (eg, ordering diagnostic tests or starting therapy for a presumed, but not actual, decline in lung function) or by the alteration of patients’ eligibility for specific jobs. In addition, Black and Asian patients could gain waitlist priority and disability benefits, while the priority and benefits now afforded to White patients would become equitable rather than advantaged. If RSEs are retained, challenges will include the promotion of transparency and autonomy by informing patients about the use of race and combatting implicit bias compounded by the use of RSEs. PFT = pulmonary function test; RSE = race-specific reference equation ConclusionAlthough the anticipated benefits of continuing RSEs to heighten precision of PFTs are quantifiable, many of the physical, social, and economic harms of doing so are not. Nonetheless, they matter ethically. Eliminating racism in medicine will involve multiple activities over the long term; however, there are concrete intentional steps that can be taken now to move closer to this goal such as the explicit inclusion of ethical considerations in ongoing deliberations that concern RSEs, their current use, and in any future transition to race-free equations. Although the anticipated benefits of continuing RSEs to heighten precision of PFTs are quantifiable, many of the physical, social, and economic harms of doing so are not. Nonetheless, they matter ethically. Eliminating racism in medicine will involve multiple activities over the long term; however, there are concrete intentional steps that can be taken now to move closer to this goal such as the explicit inclusion of ethical considerations in ongoing deliberations that concern RSEs, their current use, and in any future transition to race-free equations.