A Patient’s Right to Discriminate

The results of an interesting lawsuit, from Off the Charts, the blog of the American Journal of Nursing:

Brenda Chaney brought suit against the nursing home for complying with a resident’s request not to have any black health care workers provide care or enter her room. (She also claimed her firing had been racially motivated. The court agreed that it seemed discriminatory.) The court agreed with Chaney that by acceding to the patient’s wishes, her employer created a hostile workplace and violated her rights. The nursing home claimed it was protecting the patient’s rights and that not doing so “risked violating state and federal laws that grant residents the rights to choose providers, to privacy, and to bodily autonomy.” The court did not agree.

Of course, most people think, in the abstract at least, that it’s pernicious and wrong to believe race affects the provision of health care, and a request for treatment only by “white” staff takes racism to some bizarre extremes.

I would agree. Patients shouldn’t be able to pick their nurses on the basis of race — and yes, I have heard that request voiced more than a few times. Frankly, I don’t see the necessity of pandering to anyone’s bigotry, any more than I would tolerate racism towards a patient from my colleagues. Some behaviour crosses the line, and while nurses must treat their patients with respect and dignity, it’s also a two-way street.

While health care professionals’ indelible personal characteristics may be irrelevant to providing good care, can one apply this point of view absolutely in dealing with patients in all circumstances? Does it override one of the cornerstones of health care ethics, patient autonomy, the right of  the patient to decide the course of their care? Matters are much trickier than they might first appear, for they require providers treading through a minefield of strongly held personal, religious and cultural beliefs. Then there are pragmatic aspects to consider. For example, a nurse might well hesitate before assuming care of a racist patient, on the basis the patient might be more inclined to make false complaints about his practice. Another example: as a charge nurse, I will ask female nurses, rather than my male colleagues, to perform intrusive procedures like ECGs (which require exposure of the chest) on female Muslim patients, because I believe it’s expedient to providing the best possible care for the patient. But in emergent cases, any set of skilled hands will do, for exactly the same reason, which suggests to me patient autonomy is always constrained by patient acuity, regardless of personal attitudes towards those providing treatment and care.

Some thought experiments to consider:

1. A Muslim or Hasidic Jewish patient requests same-sex nurses only, and refuses care from a nurse of the opposite sex. Is this different from refusing care because a patient is uncomfortable with a person’s race? Why?

2. A fundamentalist Christian doesn’t want to be touched by a gay male nurse, on religious grounds. Should she able to refuse care on the grounds of the nurse’s sexual orientation? Is this different from the Muslim or Hasidic Jewish patient?

3. What if it’s your ailing, elderly Gran, normally a sweet, kind lady, except for that adamant blind spot about blacks/gays/male nurses? What would you tell her? What if she was dying?

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  1. #1 by boris on Thursday 14 October 2010 - 1522

    If I have time later, I might post a more nuanced response. But on the surface I think the title of the post reveals the answer: There is no right to discriminate based on race/gender/orientation/etc. Therefore patients under care have no inherent right to make such a request, so the choice is for the patient, in my no-medical-background view becomes one of either accepting care from available providers or refusing it.

    That said, I think there is a difference when it comes to gender. Intimate or invasive care is uncomfortable enough as it is and does not need to be made more so. For example, something like urethra catheterisation might pose a real problem for someone who is uncomfortable, for any number of reasons with strange men or women probing their bits. Beyond religion, I might imagine that a patient who has a history of sexual abuse, or has never had anyone but their partner touch them, etc might really be uncomfortable with care. Society might be moving towards gender-equality but that is not the same thing as gender-neutrality and there are real differences both in cultural construction and physicality regarding gender that require nuanced attention. Put another way, someone requesting care from a specific gender isn’t likely discriminating from some form of anti-male or female bigotry but from their relative level of comfort with being treated by one gender or the other. Where that bias comes from is irrelevant.

    On your third point: 40 or 50 years ago, my gran would have forbidden her kids from dating or associating with non-whites. A couple of years ago when her emerging dementia started to break down her brain-mouth filter, she was in the hospital for some physical health issue or another (bowels I think). One of her male doctors was of non-white extraction and my dear old gran let him know in no uncertain terms exactly what sort of carnality she would like to have got up to with him if she were a few years younger. The doctor’s bottom was not safe within reach of her hands. So I suppose there’s a flip side that ailing gran with the blindspot.

  2. #2 by Terri on Thursday 14 October 2010 - 1630

    Food for thought for sure. I saw the original posting and then read yours and think you bring up valid points. This is a complicated ethical and legal issue. In the same way a person has a right to refuse care, can they refuse who provides it to them? The bottom line is, do patients have autonomy and should they have authority in their health care decisions, whether miss-informed or not. Our job is to inform them, educate them, and respect them. Beyond that, acuity does trump.

    Good questions and post.

  3. #3 by NNR on Thursday 14 October 2010 - 1847

    “Right” or not, why force the point and make everyone uncomfortable by having an RN care for a patient who is going to be hateful? I wouldn’t want to be that RN. Technically I believe no, patients should not be able to refuse care from someone on the basis of color, religion, and so on, but in reality…it’s probably easier. A related topic, though, for me is close to the EKG scenario mentioned in the post. In my department, female nurses take the assignments we’re given and perform the necessary patient care (whether it’s a giant violent patient or a man who needs a Foley, etc). But the male nurses are excused from caring for GYN patients and ask us to catheterize female patients. I see the reasoning, but shouldn’t this go both ways? I’ve never seen a female nurse ask a male nurse to catheterize a male patient. We just do it. Are we being insensitive, or are the male nurses being overly sensitive? My boyfriend is an ER nurse, and he doesn’t have any answers. “It’s just the way things are.” I’ve also never, so far, had a patient say “I’d rather have a male nurse.” Lots of food for thought here, as the previous comments indicate.

  4. #4 by CPAP therapy on Thursday 07 April 2011 - 2146

    For the elderly, which is best to have? A caregive or a registered nurse? If you were to choose only one?

  5. #5 by Ed on Sunday 03 November 2013 - 1540

    It’s my ethical and legal right to choose who, and to what degree, a provider (physician, nurse, tech, student, or chaperone) participates in my healthcare, and I don’t have to explain my rationale to anyone! I mean, come on, we’re not inmates in the county jail and my healthcare is not a spectator sport. I think its ironic how females providers automatically assume its their inherent right to provide gender specific healthcare to male patients while preventing their male colleagues from the same with female patients. That’s the height of hypocrisy and workplace discrimination. I’ve been on the receiving in of such healthcare, and will never permit it again. And folks wonder why guys avoid healthcare until its too late. It’s because they know their privacy, dignity, and modesty will be thrown in the trash like so much medical waste. Whatever happened to the basic principles of medical ethics, informed consent and patient autonomy?

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