When it comes to racism in healthcare, we often write about disparities in population health or the bias minority patients may face in healthcare settings. However, another type of situation is often overlooked — when physicians must deal with racist patients.
"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," wrote Kimani Paul-Emile, PhD, Alexander Smith, MD, Bernard Lo, MD, and Alicia Fernández, MD, in a perspective article for The New England Journal of Medicine.
There is little guidance of how to proceed in these types of situations. Hospitals must balance the requirement to treat patients under the Emergency Medical Treatment and Active Labor Act, while still respecting the well-being of their physicians. For physicians, how can you proceed? For hospitals, when — if ever — should such requests be accommodated?
Drs. Paul-Emile et al., suggest the following steps for physicians and hospitals to use as a framework to deal with racist patient requests.
1. Determine the medical stability of the patient. If the patient is unstable, they must be treated and stabilized, regardless of bigotry, the authors wrote.
2. Assess the patient's decision-making capacity. If the patient is unable to make decisions, persuasion and negotiation from family members may be necessary, according to the authors.
3. Understand the reasoning behind the patient request. If the patient is stable and able to make decisions, clinicians should attempt to understand the motivation behind the request. In some instances, the request may be clinically and ethnically important. The authors give examples of a language barrier, or a Muslim woman requesting a female physician, for example. They also note minority patients may want a racially or ethnically concordant physician due to past negative experiences in healthcare that have created mistrust.
4. If the request is clearly rooted in bigotry, it is less deserving of accommodation. In the majority of cases, bigotry should not be tolerated. "No ethical duty is absolute, and reasonable limits may be placed on unacceptable patient conduct," the authors write. Only in very rare cases should a physician consider accommodating a bigoted request. The authors give the example of a veteran with post-traumatic stress disorder refusing treatment from a physician of an ethnic background similar to former enemy combatants.
5. On-call administrators should respond to the situations. In every single instance, leadership should remind patients of their responsibility to refrain from hateful speech. They can also remind patients of their right to seek care elsewhere, the authors wrote. The physician should always be comfortable with the decisions and it should not compromise good medical care, the authors wrote.
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