Should Patients Be Allowed to Choose — or Refuse — Doctors by Race or Gender?

I work for a public medical system, and we have an ethics seminar each month. The last one featured an article by a doctor in one of our hospitals. She discussed patients or their families who insist on having medical providers who are some combination of straight, white, male and/or American-born.

Some seminar participants thought patients should be able to choose such a provider in our system because they can do so in the private care system and because we now encourage them to use the private system if they prefer.

I was shocked that any providers considered it ethical to support patients’ openly making health care decisions based on bias. The point was also made that treatment is often provided in emergency settings where a patient’s life is at stake. Many of our treatment options are aimed at small populations of patients, so there may be only one practitioner available. That practitioner may not be male, straight, white or American-born. Patients cannot receive some types of specialty care outside our system, so they do not have the option of shopping around for all types of medical care. Is it truly ethical for patients to demand that their bigotry dictate who treats them? Name Withheld



Is it ethical for patients to want their bigotry to be accommodated? That’s an easy question: no, because expressing bigotry isn’t ethical. The harder question is whether health care professionals ought to accommodate their bigotry.

The picture changes when we’re in an institutional setting, one in which patients haven’t chosen their health care practitioner. The picture changes when a man with a swastika tattoo, say, announces that he doesn’t want a black nurse touching his newborn in the neonatal intensive care unit. (That’s a real case, from a hospital in Flint, Mich.) He’s not obliged to choose a particular hospital. But once he has, a hospital that accommodates his request and assigns employees on that basis is effectively instituting his bias.


Your own medical system should be careful not to make that mistake. There are more complicated cases, to be sure. What about a woman who, as a survivor of sexual assault, asks to be seen by a female gynecologist? Here, surely, it would be reasonable to try to accommodate her, not least because the choice doesn’t reflect disrespect for male doctors, as refusing to be touched by an African-American nurse does reflect disrespect for black medical staff. Not every form of discrimination is invidious. It’s perfectly appropriate for a patient who speaks Spanish to ask for a doctor who does, too. It’s a very different thing for patients to reject a doctor because she also speaks Spanish.

For health care professionals who work in hospital systems, incidents of patient bias can be wounding. That’s why hospitals should, when possible, try to accommodate staff members who don’t want to be assigned to patients who display bias toward them. A doctor’s primary concern is the best care of her patients, and we rightly hold physicians to a higher bar than we do patients. But a health care system has to attend, as well, to the welfare of its staff members.

Recently I stayed with friends and took a taxi from the airport to their house. My driver was either drunk or stoned. He drove wildly and got profoundly lost. When I remonstrated with him, he became abusive and quite terrifying. I wanted to report him to the taxi company but feared he might take some form of revenge against my hosts because he knew their address, so I held off. Should I have reported him? James Smith, Brooklyn

Yes. This is the sort of threat to the general public that all of us have a duty to report. I understand your worry that he might harm your hosts, but there are ways to mitigate that risk. Why not let the company know that his threats made you concerned that he might retaliate against your hosts — and ask them to make clear to him that the complaint came from a visitor to the area? For a reality check about your concerns, you also could have consulted with your hosts and asked them if they were O.K. with your notifying the company of what happened.

A dear friend of mine just turned 65. She never married, has never been in a long-term relationship and never had children. Her mother is dead, and her father, who is elderly, lives far away and hasn’t visited in decades. Her sibling, who is married, lives on the other side of the country; they see each other maybe once a year. I am probably her closest, if not only, true friend. She doesn’t socialize much, works very part time and lives humbly. I have two young adult children and a grandchild. I have a good career, though I am by no means wealthy. I have an active social life, though I am single as well and seven years younger than she is. My question is: When she grows old, or perhaps becomes disabled, will I be the one responsible for her care — or for decisions about her care? I can’t imagine how I’d be able to help. I’m thinking about talking to her, to seewhat her wishes are. If I do, how can I best frame the conversation? Name Withheld

You are a thoughtful friend — and both of those last two words are important. Thinking about these issues now is vastly better than trying to sort them out when your friend’s needs eventually become urgent. So you should indeed begin the conversation soon. You’ll need to discuss whether she should provide you with information about, say, whatever health care coverage she has beyond Medicare, and whether she wants to give you (and whether you’d accept) power of attorney for paying her bills or making medical decisions. Either way, you might encourage her to write down what she wants done in the event of serious illness and — if she doesn’t want to involve you — to have her communicate with her family about these things. If any legal work is involved, the two of you should go to a lawyer at some point to discuss and record your agreements.

In these conversations, you, too, will be working out what you are and are not willing to commit to. That’s something to give thought to before you start talking. You ask whether these responsibilities will inevitably fall to you. They wouldn’t if you were sure you were unable or unwilling to handle them. But if that’s true, the time to say so is now, when it’s possible for her to think about alternate arrangements.

It is plain, though, that you wouldn’t be able to stand by and do nothing if she needed help. That’s why it’s important to have a clear understanding of how you both want things to play out as she needs more help over time. If the conversation goes well, you’ll also have given her something immediate: the reassurance of knowing that a caring friend is looking out for her.

And by the way, your friend is, demographically speaking, far from an outlier. In “Going Solo,” the sociologist Eric Klinenberg has noted that the number of Americans who live on their own is eight times as high as it was in 1950. It’s a trend he attributes to various factors, including the fact that women are economically more independent than they used to be, and even women who marry are increasingly likely to outlive their partners by a decade or more. All of which is to say that the issues your friend is facing will face more people as time goes on.

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