Racism and the Margins of Respect for Autonomy

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By Doug Olsen, PhD, RN

The recent allegation that a father at a Michigan hospital requested and was granted a change of nurse for his newborn son, based on the assigned nurse’s race, has created a stir in the professional and national public media (Articles in USA Today, Washington Post, Lansing State Journal, and reports on MSNBC.) The initial gut reaction has been overwhelmingly negative, to the point of horror, that the hospital would accede to such a request. The strong reaction seems related to the accusation that the father’s request arose from hateful racism; he is alleged to have brandished a swastika tattoo while making the request.

This initial reaction is understandable, and ethical analysis must account for these concerns. The values of diversity, inclusiveness, fair access to work, and the elimination of inappropriate bias in distribution of care are essential to ethical healthcare.

However, the overall situation of patients requesting clinicians based on personal characteristics is more complex than this initial reaction indicates, because in addition to the values leading to outrage, our professional values also include allowing and encouraging autonomy of patient choice in the goals of treatment and the method of service delivery, and also maximizing the ethical therapeutic clinician-patient relationship. Better clinician-patient relationships are more trusting, have greater mutual respect, better communication, and have more clinician empathy and result in better clinical outcomes and patient satisfaction (Atlas et al., 2009; Thom et. al, 1999; Larson, Yao, 2005). Optimum clinician-patient relations are essential for the moral discernment essential to ethical care, including shared decision making and patient-centered care.

Choice of clinician is recognized as an emotional issue: U.S. insurance health-plan marketing often cites broad choice of clinician in their public advertising, government interference in patient choice is a bogeyman of health-care politics, and patients state that they prefer choice (Harris, 2002). In addition, some requests, such as those for same-gender providers, are routinely considered appropriate and granted.

If we take the values of patient autonomy and importance of relationship seriously, denying a patient’s request for a different provider requires specific, strong justification. The clinician finding the patient’s motives as reprehensible isn’t enough by itself. A clinician’s duty to provide optimum care isn’t limited by personal judgments of the patient, just as a firefighter shouldn’t decide whether the homeowner is worthy before responding.

Justifications to limit a patient’s choice of provider based on personal characteristics include feasibility – that granting the request would unfairly disadvantage other patients or that the request arises as a consequence of a patient’s disorder and granting it would negatively affect treatment; or that granting the request would unduly harm the involved clinicians or other employees.1

In this particular case, the two potential justifications are adding to patient pathology and harming employees by creating a hostile workplace. Membership in a hate group and fringe politics is not, in and of itself, a mental disorder. But as a mental health clinician, my ears perk up at extreme inflexibility and antisocial views. However, in this case the nature and duration of the relationship make invoking this justification unlikely.

The best justification for denying this father’s request is a potential for harm to employees by creating a hostile workplace far outweighing any expected benefit of granting his request. Race-based requests for providers have been held to contribute to a hostile work environment. The Seventh Circuit Court of Appeals held that a nursing home’s policy to honor residents’ requests for white certified nursing assistants, along with methods of enforcing the policy and “racially-tinged comments and epithets from co-workers,” created a hostile work environment for an African-American employee (Chaney v. Plainfield Health Center, __ F.3d __ (No. 09-3661, July 20, 2010)). The court’s finding was based in labor law and not in relation to patients’ rights which seems appropriate to this justification.

Still there may be circumstances when a race-based request can be honored without harm to others. Indeed, there is no good to be had in forcing a patient into a relationship which will be less therapeutic than possible, or forcing a clinician to care for a patient who brings hateful feelings to the relationship.2

Regarding the clinician requested by the patient, providers are often called upon to treat patients whose personal views and lifestyles are repugnant, and patients have a right to optimum care whatever their personal characteristics or opinions. This is clear in the American Nurses Association (ANA) code of ethics. Provision one of the ANA code of ethics (2001) states, “The nurse, in all professional relationships, practices with compassion and respect… unrestricted by considerations of social or economic status, personal attributes or the nature of health problems.”

While physicians retain the right to choose their patients, the American Medical Association Code of ethics (2001) principle six states, “A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve,” the latitude of the “physicians’ prerogative” to choose patients is clarified and limited in their code’s Opinion 10.05:

“(2)…(b) Physicians cannot refuse to care for patients based on race, gender, sexual orientation, or any other criteria that would constitute invidious discrimination. . . nor can they discriminate against patients with infectious diseases.

“(c) Physicians may not refuse to care for patients when operating under a contractual arrangement that requires them to treat…”

When it is clear that racism or some other socially unacceptable reason is the basis for the requesting a change of clinician, certain limitations and understandings must be made clear to the patient: First, the patient needs to be told that the decision to grant the switch is based solely on providing the patient optimum care by providing a clinician with whom the patient can form a therapeutic bond. Second, allowing the patient to switch clinicians does not indicate the institution’s endorsement of his or her views; the patient needs to be told that the institution specifically does not recognize race or other analogous factors as the basis of any decision, and that the institution values and strives for a diverse workforce. Third, the patient’s desire for clinicians with certain characteristics may not be met at all points in time, for example, in emergencies or when no clinician with the desired characteristics is available. In addition, the patient should be assessed for an underlying pathology as extreme views may be related to a psychiatric disorder, and treatment should be offered if a disorder is diagnosed.

1Lack of decision-making capacity is the most common reason for limiting patient choice in many areas, but I am assuming that most patients who can make such a request and be consistent about the request would meet criteria for decision-making capacity.

2An argument could be made that the society and possibly the hateful individual benefits from forcing confrontation with the hated group, as this is a sometimes an effective way of breaking barriers, but this would be paternalistic, in that the patient would be forced to do something for his or her own good.

References:

  • American Medical Association. Code of Medical Ethics. 2001. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.shtml
  • American Nurses Association. Code of ethics for nurses with interpretive statements. Washington, DC: The Association; 2001. http://www.nursingworld.org/ethics/code/protected_nwcoe303.htm.
  • Atlas S, Grant R, Ferris T, Chang Y, Barry M. Patient–physician connectedness and quality of primary care. Annals of Internal Medicine. 2009;50: 325-335.
  • Chaney v. Plainfield Health Center, __ F.3d __ (No. 09-3661, July 20, 2010).
  • Harris K. Can high quality overcome consumer resistance to restricted provider access? evidence from a health plan choice experiment. HSR: Health Services Research. 2002;37(3): 551-571.
  • Larson E, Yao X. Clinical Empathy as Emotional Labor in the Patient-Physician Relationship. Journal of the American Medical Association. 2005;293(9): 1100-1106.
  • Thom D, Ribisl K, Stewart A, Luke D. Further Validation and Reliability Testing of the Trust in Physician Scale. Medical Care. 1999;37: 510–517.

OlsendougDoug Olsen, PhD, RN, is an Associate Professor in the College of Nursing at Michigan State University.

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2 Responses to Racism and the Margins of Respect for Autonomy

  1. Mike says:

    As the chair of a hospital ethics committee I agree with the analysis provided.From a provider standpoint it makes more sense to “take the high road” and excuse yourself from caring for these individuals and transfer the care to an appropriate person. Engaging in debate or argument with the individual with these “hate” beliefs is rarely productive as their views are not held from a rational logical basis. Challenging them should be done carefully and well thought out to provide an opportunity for discussion, not in the “heat of battle”. As a clinician we frequently subjugate our personal views to the betterment of the patient and society. Multiple examples are common. In the ED, treating a murderer that was injured in an arrest process, pedophiles, rapists etc. More individual example would be the decision to discuss or offer abortion as an alternative. Your higher moral compass and ethical application of the same, should be the determining factor in participation of patient care.

    • From Doug Olsen:
      Thank you for comment, I agree that the clinical setting is not the place to debate a patient’s politics, however repugnant, and that good clinical care should not be contingent on the clinician’s approval of the patient’s politics or lifestyle. As Mike points out clinicians are often called on to treat persons, whose beliefs and actions we personally abhor.
      I do think it is appropriate that when granting a request to switch clinicians for socially abhorrent reasons to inform such patients that the basis of any change in clinicians is the desire to provide a good, working clinical relationship and not as an endorsement of their views, and that the institution makes no distinctions by race. Further, that the patient’s requests cannot be granted in certain circumstances – which may include situations in which granting such requests create a hostile workplace and are thus forbidden by labor law.

      In mental health, some disorders are defined by unacceptable, even criminal, urges or behavior, for example pedophilia (See DSM-IV-TR, Sexual and Gender Identity Disorders, Paraphilias, Pedophilia 302.2). We must learn to accept that patients both suffer and do bad things, and that treatment of the suffering is not the same as condoning the behavior. Further that when the suffering is connected to the bad behavior that unconditional acceptance provides a context to help the patient alter the bad behavior.

      Your mention of abortion is interesting. I believe a standard approach would find conscientious objection (CO) to participating in an abortion different from treating a murderer. Clinicians invoke CO not because they disapprove of the patient’s views but because they have a moral objection to participating in the treatment. If my disapproval of the murderer’s action led to the conclusion that it is immoral to treat him or her then I am in the untenable position of making treatment contingent on my approval of the patient’s moral worth.

      However, I’m not satisfied with the formulation endorsing CO by distinguishing a clinician’s moral evaluation of the patient from their moral evaluation of the treatment. I am concerned that patients turned away from treatment, even when referred elsewhere, because of a moral objection to the treatment suffer unfairly from a thinly veiled contempt for patient. Clinicians and institutions should not make patients into moral pariahs for seeking socially sanctioned treatments.

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