How Should Physicians Respond to Racist Patients?

Tara Haelle

February 24, 2016

It is a rare minority physician who has not at least once encountered a patient who refuses the physician's care out of bigotry. In fact, it is one of "medicine's open secrets," Kimani Paul-Emile, JD, PhD, an associate professor of law and faculty codirector of the Stein Center for Law & Ethics, Fordham Law School, New York City, told Medscape Medical News.

"So many physicians of color can recall at least one time in their career when this came up," she said, "and there aren't meaningful guidelines for how to balance the interests at stake when these issues arrive."

Dr Paul-Emile wrote an article for the UCLA Law Review about this issue from the legal perspective several years ago. Several physicians since then have asked her to address it in a medical journal, so she and three others now present a framework for how to consider these situations in a perspective piece published in the February 25 issue of the New England Journal of Medicine.

"A patient's refusal of care based on the treating physician's race or ethnic background can raise thorny ethical, legal, and clinical issues — and can be painful, confusing, and scarring for the physicians involved," Dr Paul-Emile and colleagues write.

Even if such a situation does not occur often, "it causes a lot of heartache when it does," coauthor Alicia Fernández, MD, from the Division of General Internal Medicine at the University of California, San Francisco, told Medscape Medical News. Dr Fernández herself experienced such a situation as a resident.

"We wanted to shine a little bit of light on this because it can be so difficult for physicians, and particularly difficult for residents," Dr Fernández told Medscape Medical News. "We're trying to balance a patient's right to have some choice in who can or cannot attend to them vs the physician's right to be treated with respect and dignity in the workplace and have their employment rights protected."

Competing Interests Require a Nuanced Approach

The authors describe the various conflicting interests and legal considerations in these situations: healthcare providers' employment rights to "a workplace free from discrimination based on race, color, religion, sex, and national origin, according to Title VII of the 1964 Civil Rights Act" ;a competent patient's right to refuse medical care on the basis of informed-consent rules and common law; and the legal requirements of the Emergency Medical Treatment and Active Labor Act to screen, stabilize, and possibly treat patients with emergent conditions.

But hospitals and physicians lack guidance on how to actually juggle these interests. Therefore, the authors suggest that "sound decision making in this context will turn on five ethical and practical factors: the patient's medical condition, his or her decision-making capacity, options for responding to the request, reasons for the request, and effect on the physician."

The first step is to assess the patient's medical condition: An unstable patient should be immediately treated and stabilized. If the patient is stable, the physician should assess the patient's decision-making capacity. For example, patient requests based on bigotry "may be attributable to delirium, dementia, or psychosis," and treatment of the condition may result in a change in the patient's preferences.

If the patient is competent and their request is clinically appropriate, it should be accommodated. If a request is grounded in bigotry, the patient can be offered a transfer to another facility or physicians can employ "persuasion, negotiation and an appeal to their better nature," Dr Fernández said. The physicians may also enlist the help of family members, may decide among themselves to accommodate the patient, may allow a nurse or resident to evaluate the patient, or may attempt to otherwise negotiate with the patient.

"It's tougher when you have a competent patient who's not completely stabilized," Dr Fernández told Medscape Medical News. "They can't be transferred and can't be told to go elsewhere."

Balancing Physician and Patient Interests

The authors write that, "For many minority health care workers, expressions of patients' racial preferences are painful and degrading indignities, which cumulatively contribute to moral distress and burnout."

Bigotry can harm both the patient and the physicians and staff caring for that patient, Dr Fernández said, but competent patients retain the legal right to choose their physicians.

"At the end of the day, if a patient doesn't want you to examine them, you have to abide by that," she said.

Although physicians are generally ethically expected to "subordinate their self-interest to a patient's best interests and overcome any aversions they may have toward patients," the authors write, "no ethical duty is absolute, and reasonable limits may be placed on unacceptable patient conduct."

Art Caplan, PhD, director of the Division of Medical Ethics at New York University School of Medicine, New York City, told Medscape Medical News he found this framework more generous than he would propose.

"I think it's an admirable effort to balance patient wishes against professionalism and to be respectful of the patients, but morally, I'm less enthusiastic when you're responding to hatred, bigotry, misogyny, or prejudice," Dr Caplan said. "There are patient wishes or preferences, but I don't think we need to be always respectful of those."

He added that hospitals are under a strong obligation not to tolerate bigoted behavior, but Dr Fernández noted that the article attempts to distinguish between how an individual physician might balance all the competing issues and how an institution needs to balance them.

"We believe that institutions should not accommodate patients in stable condition who persist with reassignment requests based on bigotry," the authors write.

"For an individual physician, we think the interests are much more complex," Dr Fernández told Medscape Medical News. "We are supportive of physicians who choose to accommodate, and we are supportive of physicians who choose not to accommodate."

The framework provided does not mean physicians should always accommodate patient requests, Dr Paul-Emile added. "There needs to be a rubric or framework for providers to think about all the issues they have to consider," she said. And regardless of the approach taken, "patients should be informed that hateful or racist speech is not allowed," the authors write.

When Patient Requests Are Justified

The authors also point out situations in which a patient request to be treated or even not treated by a physician of particular race or ethnicity may be appropriate and should be accommodated.

"We draw people's attention to the distinction between a request for a same-race physician and a rejection based on bigotry," Dr Paul-Emile said. "I think sometimes that gets lost in these discussions."

For example, female patients may specifically request a female physician for reasons of modesty or cultural or religious beliefs, such as Muslim women declining care from a male. Another patient may request a physician of a specific ethnicity to overcome concerns about a language barrier. In addition, minority patients may specifically request a provider of the same minority group because of negative experiences that engendered mistrust.

"We know for communities that have faced discrimination in the past, a request for a same-race or same-ethnicity physician might increase the quality of care they receive," Dr Paul-Emile said. "We need to have a more nuanced and measured analysis for thinking about types of requests or rejections based on race."

Patients who refuse care from a particular provider on the basis of bigotry, however, are "less deserving of accommodation," the authors state, unless it is a particularly rare occasion in which the refusal of a particular physician "may be reasonable or worth accommodating." They provide the example of a veteran with posttraumatic stress disorder who refuses care from someone whose ethnic background is the same as previous enemy combatants.

"We hope this isn't the end of talking about how issues of race and bigotry enter the practice of medicine and how we need to be aware of them and have appropriate means of dealing with them when they arrive," Dr Paul-Emile told Medscape Medical News. "As society becomes more pluralistic and the core of physicians become more diverse, we need to be prepared to deal with the challenges and the promise that such necessary diversity brings."

No external funding was reported. The authors and Dr Caplan have disclosed no relevant financial relationships.

N Engl J Med. 2016;374:708-711. Abstract

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