Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on the ethical implications of a patient's request for a white surgeon.
Should the hospital provide him with an all-white surgical team?
Yes: 13%
No: 87%
If not, should they operate against his wishes or tell him to seek care elsewhere?
Operate against his wishes: 6%
Tell him to seek care elsewhere: 94%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
Requests related to the identity of a caregiver generally occur along a continuum. Some requests, like those of a Ku Klux Klan member demanding a white doctor, strike much of society as disturbing, if not repugnant. Others, such as a pregnant teenage girl requesting a female gynecologist for her first obstetric exam, appear much more reasonable to many people. Numerous cases stand in a gray area between these extremes -- for example, the African-American psychiatric patient who requests that an African-American psychiatrist evaluate him, because he fears that a white doctor won't understand what he has experienced.
Practical exigencies and consequences may also come into play: a patient who requests a home health aide of a specific ethnicity or gender and is met with rejection may find pretexts for firing aides who do not meet their requirements until their specifications are met.
While data regarding racial attitudes of patients are not available, research has shown that a sizable number of patients have personal preferences for the gender of their physicians. For instance, one showed that pediatric patients preferred female providers, while their parents preferred male providers. By contrast, a 2016 investigation found that only one in ten adults cared about the gender of their doctor -- although that percentage, at the population level, is still a large absolute number of patients. (Complicating the subject even further, a found that certain elderly patients actually achieve better outcomes when treated by female providers.)
Religious beliefs further muddle matters. Reasonable people might sympathize with the request of an Orthodox rabbi who asks for a male urologist for his prostatectomy because his religion objects to an unrelated woman touching him, if such contact can be avoided. Far fewer people sympathize with a male patient who demands a male urologist under the mistaken belief that "women are too emotional to cut straight."
Hospitals and courts would prefer to avoid the time and energy involved in investigating the motivations of those who make such race- and gender-specific requests, but in the case of John, the hospital has three distinct options. It can honor John's request regarding his care providers' race and arrange for an all-white surgical team. It can defy John's request and, declaring this a medical emergency, forcibly treat him with a multiracial surgical team. Or it can refuse to honor John's request for a white surgical team and either tell him to seek care elsewhere or go along with his request regarding his right to die if the only other option is a non-white surgeon.
Few patients are likely to hold beliefs as strong as John's on race, so accommodating such rare requests is unlikely to cause significant disruptions in the overall delivery of healthcare. Letting John die because he holds views that many find objectionable might strike many physicians as out of keeping with the nobler traditions of medicine. At the same time, honoring such requests runs the risk of stamping members of certain ethnic, racial, or gender groups with a "badge of inferiority," leading to demoralization. This effect might be particularly concerning if the same groups of providers are consistently excluded, resulting in increased social acceptance of such prejudices.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases:
Skirt U.S. Rules and Conduct Research in Africa?