Striking a Balance

July 24, 2017

By Peter Young

 

In April of this year, the Berman Institute and Johns Hopkins Hospital Ethics Committee held its monthly Ethics for Lunch case presentation focusing on how to manage patients who make racist, sexist, and otherwise offensive comments. The discussion, moderated by Dr. Joseph Carrese, featured panelists who have experienced racism/sexism in the clinic, and it allowed audience to gain insight from their perspectives.

 

During the discussion, there was mention that minority patients in an in-patient setting cannot choose their own doctor based solely on race, because Hopkins’ practice is to pair the best doctor with a patient’s medical needs. I was a bit confused how minority patients not being able to choose race-based concordance in an in-patient setting fits into the larger, nation-wide conversation of minority groups wanting safe spaces. For example, some argue the race of the physician affects the quality of care, and when the provider and patient’s race align, the provider can speak better to certain beliefs, religious practices, nutritional knowledge, and cultural norms. Also, there may be even subtler, yet equally important benefits of having your provider look like you, especially in our current political climate. This includes patient-compliance as well as the potential for less polarizing power dynamics in the provider-patient relationship.

 

Scholars like Dr. Dayna Bowen Matthew, author of Just Medicine and professor at University of Colorado, might argue that if a white, middle-class person tells an intercity, minority person to take their medication, that patient may be less likely to adhere. Other research suggests minorities may be more likely to trust a provider that looks like them, and this can contribute to patient compliance and better outcomes. When the patient/provider relationship is good, or patient feels more comfortable with the provider, it’s possible to improve health outcomes.

 

If this is the case, why can’t minority patients be offered an option for race-based concordance in an in-patient setting at Hopkins Hospital?

 

Someone against race-based concordance may argue that not assigning the best physician for each job poses a safety risk. Currently, Hopkins pairs the best available physician based on skill to attend to a patient’s medical needs. To be clear, skill-based concordance includes language proficiency, cultural consciousness, and dietary considerations (these are not attributes physicians are born with, but skills they develop throughout their lives and career). In some specialties, such as dermatology, physicians with a darker skin pigment can provide skilled information to patients with dark skin, therefore, this type of accommodation is acceptable. Assigning a physician to a patient for no other reason than skin color, however, is a consideration not based on skill and could pose a risk to the patient.

 

Suppose, for example, a mother in labor and her baby entered the hospital in critical condition. Two care teams come in, one for the mother and the other for her baby. The father and husband then enters the delivery room and states, ‘I don’t want any African Americans in here with my wife or child.’ This request is not based on anything pertaining to skill, but only skin color. If that attending physician were to accommodate the father’s request, the resulting situation could create a safety risk for the mother and child since those two care teams work together regularly and know each other’s rhythm and working style—they would be at a disadvantage by sending black clinicians out of the room. Furthermore, and more obvious, accommodating the father’s request would enable racism and could potentially cause trauma to those clinicians who are victimized by this type of action. While that harm is problematic in itself, it could also affect team dynamics and the quality of care provided in the future.

 

There could be other unforeseen problems by accommodating patients’ preferences for race. There are, for example, people in the US who may look white, but know more about the Latino culture than someone who was born in Latin American and who looks Latino. Just because someone was born into a culture and looks a certain way does not mean they can work as a provider with respect to that culture.

 

Additionally, assigning physicians to a patient solely because of skin color or gender could set a risky legal precedent since it promotes discrimination. In a paradigm where patients can choose the race or sex of their provider, there are possible discriminatory actions against women and minority providers. Take for example a patient who doesn’t want a female physician because they don’t have confidence in their skills. Other patients may only want a white male physician because those patients have more confidence in their skills, although this would be unfounded. Wrapped around all of this are issues surrounding Title IX, which Hopkins must adhere to since it’s a teaching institution.

 

Putting the legal risk aside and keeping to the conversation about ethics, the question still stands: could providing minority patients an option for race-based concordance as a policy while denying other requests for race-based preference be permissible? I ask particularly because of a history of racism in the United States, which has led some minorities to feel unsafe in certain white-dominated institutions. If race-concordance among minorities could help promote better health outcomes, then could such a policy could be seen as a legitimate way forward?

 

As a possible solution, one can consider the work of Dr. Kimani Paul-Emile, who gave a Berman Institute seminar in late 2016 titled “Dealing with Racist Patients.” Dr. Paul-Emile cites scholarship in her New England Journal of Medicine piece, which argues, “patients who are members of racial or ethnic minority groups may request concordant physicians because of a history of discrimination or other negative experiences with the health care system that have resulted in mistrust.” So a physician who practices by this philosophy would never accommodate a request for race-concordance based on bigotry. Patients can, however, be accommodated with race-based concordance if it pairs them with physicians who can understand their experiences, show them respect, and whom they can trust more.

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