Any Place for Race on the Coalface?

Last month (Feb 25th 2016) the New England Journal of Medicine published this editorial “Perspective” titled: “Dealing with Racist Patients.

In the article the authors – Drs Kimani,  Alexander K. Smith, Bernard Lo  and Alicia Fernández present this case vignette:

A 77-year-old white man with heart failure arrives in the emergency department of an urban hospital at 3 a.m. with shortness of breath and a fever. When a black physician enters, the man immediately announces, “I don’t want to be cared for by a %$#!{& doctor!” Taken aback, the physician retreats from the room. She’s offended by the man’s rejection and demeaning language — but knows that he may have a serious medical condition and that she cannot treat him against his will. How should the physician proceed?

This is followed by a discussion around the ethics and legalese aspects faced by physicians when dealing with overtly racist patients in the ED.

There is even a flowchart to assist the decision-making around this scenario.  Probably a good idea to have a “checklist” when dealing with a potentially emotional and heated discussion.

Please have a read of the article and come back here for my thoughts.

Last week I had the chance to discuss this paper and the issues raised with a few of my colleagues – and there were some interesting opinions.  To give you some context our ED is very much an Aboriginal ED – about two-thirds of our patients are Indigenous Australian people.  Our staff include a mixture of local, Anglo/European Aussies, overseas-trained doctors and our fantastic local Aboriginal health workers.  Being racist is not really an option if you work in the Kimberley – or at least it would be a very unpleasant existence. We do see a bit of “reverse racism” particularly directed at our overseas-trained doctors.  So it was interesting to read this article and see how it works in the U.S of A.

The authors of the paper broke down the ethical considerations based upon the patient’s reasons for refusing a particular doctor

  • Incompetent patient: – clearly these folk need to be treated under a duty of care. Don’t see much to gain by fuelling a conflict in this scenario.  If a patient does not have capacity to make decisions then it comes down to the family.  I would tend towards uber-pragmatism here and offer whichever physician will cause the patient the least distress.  But… Racism on the part of the family should not be included in this compromise.
  • Patient preference based on “clinically or ethically appropriate reasons” – this is a little bit tricky.  Examples are given:
    • Female patients requesting a female doctor.  (This is often the case in Aboriginal Health in Australia – it is generally culturally inappropriate for male clinicians to perform intimate examination of female patients [and vice versa].  There are of course degrees of ‘intimacy’ and traditional beliefs.  We also have varying capacity to accomodate this scenario – I work solo nights, so cannot offer this at all times.)
    • Patients who request clinicians with same language.
    • Patient with negative experiences with a particular racial group – e.g. veterans of war conflict rejecting clinicians from their former enemy country.
  • I would add another group of patients that I have come across; patients that request a different clinician based upon “undisclosed” reasons… for example a homophobic patient may refuse to see a doctor that they suspect to be a homosexual.
  • Finally there is the overtly racist or bigoted patient.  These are somewhat easier to classify, however the conflict is usually front-and-centre.

The authors also raise the potential for conflict between the patient’s wishes and the employer’s [hospital] duty to provide a safe and non-discriminatory workplace.

Of course, being the USA there is alway the potential for physicians to take civil legal action against these patients.  This hasn’t happened yet.  I cannot imagine it happening in Australia  – but it does raise another set of ethical questions.  Should a physician take legal action against a patient in this setting?  Certainly we pursue criminal charges in the case of staff being assaulted.  How is this different ethically?  Is a verbal “assault” based on race, gender, religion or sexuality different if a punch is never thrown?

So after a bit of debate and thought I have boiled this down to two basic options in my head.  If I was in this situation there are 2 practical options:

  1. Acquiesce to the patient’s request and provide another clinician
  2. Decline the request, run the risk of conflict, but remain “ethically intact”.  That is, place the principle before the patient.

So how to decide which way to play any given scenario…..

For me the central, critical question is around the underlying patient motivation.  You might ask yourself the following questions:

Is the patient refusing a particular doctor in a genuine attempt to enhance their own care?

OR

Are they placing their care behind their irrational, false belief that the treating doctor is in some way inferior.

So put yourself in this situation:- you are the duty consultant and a patient is kicking up a bit of fuss after being allocated a doctor who was trained in Pakistan.  The patient has no other information about the junior doctor other than his name – Dr Mohommed Hafeez Bilal and that he has a strong Pakistani accent.  The patient doesn’t appear to have a life-threatening condition but it is looking like he will need admission for ongoing investigation.

Q1. How will you deal with this patient?

Q2. What will you tell Dr Bilal?

Q3.  Do you have another, smarter way of breaking this down?

 

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