Kimani Paul-Emile co-wrote for the New England Journal of Medicine an article that addresses how to respond to patients who reject physicians based on race or ethnicity.
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?
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. And we fear that race-based reassignment demands will only increase as the U.S. physician population becomes more racially and ethnically diverse. So we’ve created a framework for considering and addressing such demands.
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Physicians and other health care workers have employment rights that must be balanced with patients’ rights. Employees of health care institutions have the right 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. Organizations that make race-based staffing decisions or compel employees to accede to a patient’s request for reassignment on the basis of a worker’s race or ethnic background may violate Title VII. Nurses and nursing assistants have successfully sued employers who require employees to accommodate such demands by patients.
Physicians, however, have not brought such lawsuits, perhaps for two reasons. First, unlike nurses, many physicians are not hospital employees but rather “independent contractors,” who are not covered by Title VII unless the hospital exercises a substantial amount of control over how they perform their jobs. Second, physicians commonly decide among themselves how to address reassignment requests and thus probably are not often forced by a hospital employer to accommodate such requests.
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The final consideration is the effect on the physician. For many minority health care workers, expressions of patients’ racial preferences are painful and degrading indignities, which cumulatively contribute to moral distress and burnout. Physicians must balance several ethical obligations. They should respect patients’ informed refusals of medical interventions. They should also subordinate their self-interest to a patient’s best interests and overcome any aversions they may have toward patients. Still, no ethical duty is absolute, and reasonable limits may be placed on unacceptable patient conduct. Institutions can track and collect data on these physician–patient encounters, including their effects on physicians and their ultimate resolution, with the goal of supporting staff and improving the handling of these situations.
