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The setting is a swamped public hospital emergency department in a major U.S. city. A busy ER attending is struggling to juggle the care of major traumas and the many acute, but less urgent patients waiting to be seen. He walks into an examining room to see an elderly, African-American woman. She complains that she has been waiting for 45 minutes to be seen. The physician apologizes for the delay and begins to question her about her symptoms.
Before she details the complaint that has brought her to the department, however, the woman gently inquires whether the doctor, also African-American, is indeed a physician. He assures her that he is.
"Your mother must be very proud," she remarks softly. Then she states quietly but firmly that — although she is sure he is a fine physician — she would feel more comfortable with a white doctor. "It’s just the way I was raised."
Despite the physician’s attempts to reassure her of his training, credentials and standing within the hospital, she will not relent. "Very well," he sighs, turning to leave. "You can have a white doctor. But, you’ll have to wait another 45 minutes."
The scenario described above is fiction; it occurred on a recent episode of the television series ER. But, it represents a not-uncommon occurrence in many hospitals and other health care settings.
A patient, for any number of reasons, requests that he or she receive care by a clinician of only a specific ethnic or racial group or gender. Or, to be more exact, the patient asks not to receive care from a certain caregiver due to that person’s gender, race or ethnicity.
These situations present difficult ethical challenges, say both medical and ethics experts. And unfortunately, there are no clear answers.
Should the physician, as part of a patient-centered focus on care, attempt to abide by the person’s wishes in the interests of ensuring him or her a comfortable experience? Or does the clinician have an ethical responsibility to not permit discriminatory practices against qualified health providers to become part of the practice at his or her institution?
"It’s a difficult question because I really think we have contradictory policies in the United States about this kind of stuff," says John Banja, PhD, associate professor in the department of rehabilitation medicine, and a clinical ethicist at the Center for Ethics at Emory University in Atlanta. "On one hand, it would certainly seem that no health care institution would want to accommodate patient wishes that could cause the institution to be discriminatory. The law says, on one hand, that the institution should toe the line when it comes to the law [about nondiscrimination on the basis of race, sex, or ethnicity.]"
On the other hand, he notes, ethical standards — and Joint Commission requirements — mandate care that is sensitive to the patient’s culture and outlook.
"For example, there are some cultures and religious groups with certain proscriptions about caregivers of the opposite sex," Banja says. "It is not really a personal bias with them, but a deeply held cultural or religious conviction. In essence, a hospital must operate according to two sets of rules that are almost contradictory."
Many experts would distinguish between a request that might be based in an understandable — though unfounded — concern and a request that is purely rooted in racism, sexism, or ethnic bias, says Rosalind Ekman Ladd, PhD, professor of philosophy at Wheaton College in Norton, MA. Ekman Ladd is a member of the ethics committees at two Rhode Island hospitals where she also teaches.
"I think the reason is important," she notes. "If there are certain reasons that are parts of someone’s cultural or religious identity. That is not really prejudice, particularly the male-female thing."
Health care providers should understand that such a request for a caregiver of some specific race, gender or ethnic background is not necessarily based in racism or sexism, adds Larry Davis, the Desmond Lee professor of racial and ethnic diversity at the George Warren Brown School of Social Work at Washington University in St. Louis.
"The field is moving toward recognition that requests of this nature many times are due to [the patient’s] desire for a caregiver who is like me, who understands me, or who I think will provide the care I need,’" he says. "It is not always motivated by racism, although there are instances where that is certainly the case."
But, for example, a woman who prefers a female physician may not be stating that she feels male physicians are bad or that she does not like them, she simply prefers a female physician because she is more comfortable that way," adds Davis.
Followers of many different religious traditions may have objections to opposite-gender caregivers, or to being touched by certain caregivers in a particular way, Ekman Ladd adds.
However, frequently there are patients who demonstrate racist and sexist attitudes in health care settings and, this, Davis says, is a different problem.
"You have what I consider the noble reasons and the ignoble reasons. The ignoble reasons are out there," adds Davis.
Davis has taught educational seminars in a number of hospitals focused on teaching providers how to handle racial, ethnic, or gender-based requests for care.
"I have had many nurses tell me that they have walked into a room and had the patient yell, Get that n— out of here!" he relates. "So that is out there. It is not a situation that will be unfamiliar to anyone reading this."
"I don’t think hospitals should accommodate views that are frankly and unabashedly racist," Banja says. "If you have a person point blank state that, I do not want an African-American taking care of me,’ I think that a hospital ought not to accommodate a wish like that. Yet, there are other instances that we would accommodate that aren’t terribly far away from that."
An archive of a recent Internet discussion on the Bioethics Discussion Pages Web site (www-hsc.usc.edu/~mbernste/index.html), covered the topic of racially or ethnically based patient requests.
Scenarios related by participants included a European-American man about to receive home health services from the hospital’s designated provider who demanded that only white nurses be sent to his home. Another post detailed a case of a patient of Korean descent who refused to follow the recommended medical advice provided by his physician, who was of Japanese descent, because the man believed the physician, due to historical prejudice, would be likely to try to harm him. When visited by a doctor not of Japanese ancestry, however, the man accepted treatment and his condition improved.
Many people would be more sympathetic to the second man’s situation, Banja says. "In the first case, I would say, absolutely not, I would not honor a request that was solely based in prejudice and dislike," he notes.
But, at their core, are the situations really different?
There was no real reason for the Korean man to believe that the doctor would try to harm him, and by removing the patient from that doctor’s care, it essentially reinforced a discriminatory stereotype that had nothing to do with the physician’s abilities, he explains.
But, in a crisis situation, it is unlikely that you will be able to change anyone’s mind, and arguing with the patient or attempting to influence his or her wishes may be detrimental, notes Ladd. "Another thing to consider, however, is how easy it would be to find someone to comply with the patient’s wishes. If you are dealing with a large group of nurses or doctors, that is one thing. But, if you are dealing with very few choices or possibilities, then that is something different."
If a patient’s request is motivated by their real concern for their health care or a desire for a provider who they feel more comfortable with, Davis feels this should be accommodated if such a provider is available.
In a situation where a patient has expressed an unacceptable racial or sexist attitude or behaved abusively toward staff of a particular group, he feels that, first, the staff should express to the patient that his or her views are unacceptable.
"It is important for a doctor or caregiver in the nondiscriminated-against group to step in immediately and tell the patient, We don’t agree with what you are saying. We don’t support those kinds of attitudes and distinctions here. We do try to accommodate patients’ wishes when we can. To the extent that we can accommodate you, we will, but we don’t share your attitude and we cannot guarantee that we will always be able to do what you ask."
The other staff members also need to immediately go to the health care worker who was slighted by the patient and express their disagreement with the patient’s attitude, reiterate that the caregiver will not be allowed to be abused in any way, he adds.
"This attitude needs to come from the top down," Davis adds. "Too many times, we focus on the client and how to deal with that person. But, there is another person — the health care professional — who has been hurt by this. At the end of the day, a white doctor and a black doctor may have both had a long, trying day, but only the black doctor has had to deal with being called a racial slur."
It’s also important to state that no member of the staff will be treated with any amount of physical or verbal abuse or disrespect, and the administration should follow that up, notes Davis.
"It may get to the point that if a patient is unable to restrain his or her emotions, you may have to be willing to ask that person to seek care elsewhere," he adds.
As important as it is to keep the patient’s best interests in the forefront, it is equally important to the overall institutional ethics of the hospital, that racist, sexist, or ethnic biases not be allowed to be reinforced.
"You can’t have doctors in the majority feel that Hey, I’m lucky. The patients all like me. I don’t have that problem." Davis says. "They need to feel a responsibility to support that other doctor or nurse or caregiver and let that person or people know."
As for the home health scenario, Ekman Ladd believes more weight should be accorded a patient’s wishes in a home health setting than, possibly, than in an acute-care setting, she says.
"If the reason seems to be plain old prejudice, that is a hard one," she notes. "But, it might be a little different in a home care situation. There you are on the patient’s turf, not on your turf, and I think there may be more reason for the patient to be able to say, I want this person and not that person.’ It is a more intimate situation, you are dealing with the whole family and with the home."
Regardless of whether the request may seem more understandable, or whether it can or will be accommodated, most experts don’t recommend allowing the request to go unchallenged completely.
"In some situations, a hospital representative may want to respond and say, We recruit and hire and maintain people whose intentions are above board and who are not going to be corrupted by history of political animosity or whatever," Banja says. "Not addressing that issue, that is the downside of trying to accommodate."
Whenever a hospital decides to accommodate a peculiar or idiosyncratic request for care, they ought to be able to justify or explain it in a way that most people in our society would accept, he adds. "That, to me, takes it one degree closer to acceptability than the other situation."
With the advent of managed care, with its prescribed lists of preferred care providers, patients are left feeling that they have little choice and control over their health care, Ekman Ladd believes. "I guess I am more sympathetic to patients wanting to choose when they may not be that comfortable with doctors and nurses anyway."
She feels that diversity training and cultural sensitivity training are essential for providers if they are going to be able to address these types of patient concerns and requests.
"I feel strongly that the people on the health care side need to go through cultural and diversity training so they can help make people feel comfortable with these kinds of differences. Sometimes the discomfort level comes from both sides."
• Rosalind Ekman Ladd, Wheaton College, Attn: Communications Office, 25 E. Main St., Norton, MA 02766.
• John Banja, Emory University, Center for Ethics, Suite 302, The Dental Building, 1462 Clifton Road N.E., Atlanta, GA 30322.
• Larry Davis, Washington University, Campus Box 1196, One Brookings Dr., St. Louis, MO 63130.