Blog | Wednesday, March 13, 2013

Should we let patients choose nurses by race?

A few years ago a medical resident came to me after seeing a patient.

"The patient wants to see an American doctor," she said.

I have no idea what was going through the patient's head. When people are sick, they are vulnerable, scared. Perhaps her mild accent put him off. Or maybe he came in looking for a fight. Who knows?

Not long ago I was talking to an elderly retired surgeon. He was one of the first black trauma surgeons in the area and the top of his field. He said he would regularly walk into a trauma bay to have an African American patient say, "Get your black hands off me and get me a white doctor!"

Maybe she knew that white patients always got better care, care that was usually delivered by white doctors, and she didn't want to be denied that care. Or maybe she was just cranky. Who knows?

We all have certain images of who we expect our doctor to be, and we all have or prejudices. As doctors our job is to do the best for our patients. We may not always like them or their opinions, but we have to learn to work around it, and if we can't, we have to refer them to someone who can.

Given that our duty is to serve our patients, how should we respond to a request like this? Not too far from me, a patient requested that no black nurses care for his newborn. This must have put the hospital staff in an uncomfortable position. I would hope that in a similar situation I would act in a way to preserve the dignity of my patient and the staff. Or I could get it completely wrong, as the hospital did and reassign non-white nurses.

But why shouldn't a patient be allowed to choose who cares for him?

There are ethical and practical problems that I'd like you to think through with me.

A hospital patient (or in this case his newborn) often cannot choose to simply pick up and go to another hospital. It may jeopardize his health and put him in danger. The hospital has the responsibility to give the patient the best care they can and to respect his dignity and autonomy as much as is practical.

But this doesn't mean a hospital must fulfill every request. A patient might insist on more narcotic medications, and the doctor may think it unwise. Here, the responsibility of the doctor is to explain to the patient why he or she thinks it would be in patient's best interest to avoid narcotics. The key to preserving the dignity and autonomy of the patient is informed consent. Patients must be given sufficient information to make good decisions.

But hospitals also have responsibilities to their employees. For example, they must provide a safe workplace. In this case, the hospital, by acceding to the patient's request, attacked the dignity of the nurse. This is not about hurt feelings. If the patient had complained that a particular nurse wasn't, for example, washing her hands, then the hospital should investigate this for the good of the patient. But there is no rational argument that a nurse's skin color is harming a patient. Since it does not degrade patient care, and it diminishes the rights and dignity of the nurse, the request should have been denied.

The patient should have been told, without judgment, that their request cannot be met. It is then up to the patient to decide what to do. In the case of a minor, the hospital must also think of the young patient. If the father intends to walk out before the baby is ready because of the race of the nurse, the answer isn't to pull out the nurse but to call the proper child protective authorities.

I'm not saying these decisions are easy; it's far too easy to give into our emotions, to tell a patient like this what you really think of their request, but that would only fulfill your own desire to be heard, rather than the patient's and staff's needs.

It's also easy to run roughshod over the staff's rights to keep the patient happy. But it's not right.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.