Doctor writing a prescription
The video is appalling in its brazenness: a woman in the Canadian city of Mississauga demanding, loudly and repeatedly, that her son receive medical treatment only from a white pediatrician.
"Can I see a doctor, please, that’s white?" she says in the now-viral video. "That doesn’t have brown teeth, that speaks English?"
Many viewers were shocked and outraged by the video, but for doctors and nurses all over North America, these bigoted demands are familiar and getting more frequent. Many can recount instances in which patients have used derogatory language and slurs or, as in this case, refused medical care outright based on a physician’s racial or ethnic background.
Dr. Lachelle Dawn Weeks is a physician at Brigham and Women’s Hospital in Boston who, as chair of the hospital’s social justice committee, is well acquainted with this problem.
"I thought it was incredibly sad to see this degree of overt racism play out on video," she says. "However, this overt display of bias and racism is, in my view, an extension of unchecked subtle racism that minorities experience daily in health care."
The problem is widespread. A 2011 survey conducted by researchers at the University of Calgary and University of Alberta found that 25 percent of family medicine trainees reported having been harassed or discriminated against based on their ethnicity or culture. Women, religious minorities and LGBT individuals have reported similar mistreatment by patients.
Almost as disturbing as the incidents themselves, however, is the lack of any consistent response from hospitals and medical associations on how to confront these issues. There are few guidelines for physicians — and virtually no official policies — on what constitutes a just response to blatant bigotry from patients and their families. The responsibility for navigating these fraught interactions tends to fall to individual physicians, often the same people receiving the brunt of the abuse.
At issue is a balance of rights: for patients, the right to medical care from a provider of their choice, and for physicians, the right to a workplace free of discrimination and harassment.
Barring policy protecting both, the current medical system often defaults to catering to patients’ biases. Health care providers are often pressured or told overtly to capitulate to bigoted demands. Physicians are also trained to work through subtle discrimination, Weeks notes, like name-calling or constant questioning of credentials and skills. The notion that patients are customers whose whims and preferences must be respected helps fuel the willingness to indulge prejudice.
In a particularly egregious episode in 2013, a hospital in Flint, Mich., posted a notice on a newborn baby’s assignment clipboard reading: "No African-American nurse to take care of baby." The note was allegedly posted at the request of the baby’s father, for whom the hospital also arranged the staff work schedule to avoid care by black nurses. A neonatal nurse later sued the hospital for discrimination.
"People who behave this way feel they can say and act out their bias without consequence," says Weeks. "And perhaps this is in part secondary to the lack of concrete non-discrimination policies that hospitals have about patient and family behavior towards health care workers and staff."
This realization is leading to a sea change within health care. For the first time, policymakers around the country are attempting to develop guidelines detailing not only how to protect patients from possible biases from physicians — an area that has received substantial attention within medical training — but also how to protect physicians from abusive patients.
These efforts usually begin with a crucial caveat: that emergency and lifesaving treatments must always be provided without delay regardless of patient or provider race, creed or religion.
In clear cases of bigotry, however, like the one depicted in the video, many argue that requests to change physicians should no longer be accommodated. Hospitals may go further, reserving the right to refuse care to patients if they persist in bigoted demands and, if necessary, transferring care to an alternative hospital or clinic. These changes, if successfully implemented, would be a significant step in the right direction.
There are clinically and ethically appropriate reasons why a patient might request a different physician from the one assigned to him or her. Many consider it acceptable for a woman to request a female gynecologist, or for patients who speak a particular language to ask for physicians who also speak the language. Veterans sometimes want to discuss their post-traumatic stress disorder with someone who is also a veteran. As in many ethical issues, there is a significant gray area surrounding physician preference that should be addressed on a case-by-case basis. This doesn’t, however, obviate the need for clear guidelines when dealing with clear abuses.
In coming decades, the physician population in the United States is expected to become increasingly racially and ethnically diverse, as well as predominantly female. As rates of hate crimes and bigotry increase, this likely also means an increased incidence of bias and discrimination on the part of patients. It is not enough for hospitals to pay lip service to tolerant work environments. We need clear policies to show that bigotry will not be accepted when it impugns professionalism or patient safety.
Brit Trogen is a medical student and Rudin fellow in medical ethics at New York University School of Medicine. Dr. Arthur Caplan is head of the Division of Medical Ethics at NYU’s medical school.