Ermingarden (![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png)
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agonyaunt2022-06-07 09:20 pm
ermingarden) wrote in agonyaunt2022-06-07 09:20 pm
Entry tags:
The Ethicist: Can I Withhold Medical Care From a Bigot?
I am a physician, and last year, I took care of a white female patient in the hospital for a bacterial bloodstream infection. A few days into her stay, she began referring to Black staff members by the N-word and to our receptionist by an anti-gay slur. As the supervising physician, I made it clear that this was unacceptable. In general, with challenging patient behavior, I find it best to clearly lay out expectations and the consequences for violating them. So before talking to her, I discussed the situation with the nursing staff and hospital risk management, and we concluded that if she persisted in using this language, we would discharge her from the hospital, against her will if necessary.
I made all this clear to the patient. Thankfully, she stopped and completed the rest of her hospital treatment. But if she had continued using racist and homophobic slurs, would I have been wrong to force her to leave the hospital? Although she was medically stable, and we would have sent her home with oral antibiotics, a discharge would have been substandard care: Had she been discharged and not sought care with IV antibiotics elsewhere, there is a very real possibility that she could have died from her infection.
Is hate speech grounds for refusing medically necessary care? I was taught in medical school that physical violence against staff, or the credible threat of violence, is grounds for refusing care, whereas rude, insulting or mean behavior from a patient is not. Hate speech seems to me to fall between these two categories.
Several Black nursing staff members felt strongly that this is what we needed to do, and I felt it was important to unequivocally support them. (I am a Hispanic, cisgender male.) But the patient had a substance-use disorder. This does not excuse her behavior, but it does put her in a more vulnerable category of patients. My assessment was that she was competent to make medical decisions, but I worry that her disease might have interfered with her ability to fully appreciate the consequences of her actions. Name Withheld
The responsibilities of clinicians should be configured in the light of the long experience of their professions. But these are social roles, and — given that we can all end up as patients, and we all contribute to the provision of health care resources — society has a part to play in determining what they should be. What we’ve decided is that the norms governing medical care are to be primarily concerned with the welfare of the sick. The workplace environment should minimize avoidable injury and insult to health care providers, but not at the expense of that basic aim.
It was entirely proper to tell this patient to stop using racist or homophobic slurs — language that’s offensive whether or not it is addressed to those it derogates. And the Black members of your nursing staff justly value a workplace in which they are treated respectfully; that’s surely something every employee deserves. The question is what you should do when someone ignores this simple moral demand. And here your first consideration must be the risk to a patient of discharging her.
This woman wasn’t in your hospital for some optional cosmetic procedure. She was being hospitalized for a possibly lethal condition, and as you say, discharging her meant providing her with substandard care. Had you done so, you would have violated a central ethic of your profession: that every life is of equal worth (even the lives of those who deny that tenet), that nobody should come to unnecessary harm owing to a caregiver’s decision.
The reason you can discharge someone who poses a serious threat of violence to others in the facility is, roughly, that if we face a choice between seriously endangering Jamie and seriously endangering Alex, and Jamie is the source of the danger to Alex, we should prefer the threatened person to the threatener. We’re essentially choosing between bad medical outcomes; in a clinical setting, knives should be wielded only by surgeons. That wasn’t the situation you faced. Hate speech produces what some legal scholars would deem a “dignitary affront”; and a dignitary affront, however much we deplore it, is not a medical crisis. Your primary brief wasn’t to calibrate the harms done by hate speech to the climate of your workplace. It was to ensure your patient received appropriate care, whether in your hands or others’.
Let me note, too, that the freight of words is affected by who’s speaking them. Patients — perhaps as a result of sepsis-associated delirium or certain neurological disorders — may not be in control of their speech; people who are subject to Tourette-syndrome-related coprolalia should not be denied medical treatment because their words make clinicians uncomfortable. And your patient? She had a problem with substance use and employed language that is, increasingly, stigmatizing of the user. She had no power over the clinicians who attended to her and to whose decisions she was subject. One indication of her lack of status is that your hospital’s risk managers evidently decided that the institution could safely eject her without being held accountable for the consequences. Though they didn’t intend to mete out a punishment that might have amounted to a death sentence, the risk managers effectively put the hospital ahead of the patient.
The duties of medical professionals are demanding. In wartime, a medic can have the responsibility of saving the life of a wounded enemy soldier, even if the soldier has just killed one of that medic’s friends. The fundamental clinical imperatives — evolved, collectively, over generations — shouldn’t be hastily set aside. Clinicians have duties of care to patients, even odious ones. And the more serious the likely consequences of refusing care, the larger the burdens they should be willing to accept.
I made all this clear to the patient. Thankfully, she stopped and completed the rest of her hospital treatment. But if she had continued using racist and homophobic slurs, would I have been wrong to force her to leave the hospital? Although she was medically stable, and we would have sent her home with oral antibiotics, a discharge would have been substandard care: Had she been discharged and not sought care with IV antibiotics elsewhere, there is a very real possibility that she could have died from her infection.
Is hate speech grounds for refusing medically necessary care? I was taught in medical school that physical violence against staff, or the credible threat of violence, is grounds for refusing care, whereas rude, insulting or mean behavior from a patient is not. Hate speech seems to me to fall between these two categories.
Several Black nursing staff members felt strongly that this is what we needed to do, and I felt it was important to unequivocally support them. (I am a Hispanic, cisgender male.) But the patient had a substance-use disorder. This does not excuse her behavior, but it does put her in a more vulnerable category of patients. My assessment was that she was competent to make medical decisions, but I worry that her disease might have interfered with her ability to fully appreciate the consequences of her actions. Name Withheld
The responsibilities of clinicians should be configured in the light of the long experience of their professions. But these are social roles, and — given that we can all end up as patients, and we all contribute to the provision of health care resources — society has a part to play in determining what they should be. What we’ve decided is that the norms governing medical care are to be primarily concerned with the welfare of the sick. The workplace environment should minimize avoidable injury and insult to health care providers, but not at the expense of that basic aim.
It was entirely proper to tell this patient to stop using racist or homophobic slurs — language that’s offensive whether or not it is addressed to those it derogates. And the Black members of your nursing staff justly value a workplace in which they are treated respectfully; that’s surely something every employee deserves. The question is what you should do when someone ignores this simple moral demand. And here your first consideration must be the risk to a patient of discharging her.
This woman wasn’t in your hospital for some optional cosmetic procedure. She was being hospitalized for a possibly lethal condition, and as you say, discharging her meant providing her with substandard care. Had you done so, you would have violated a central ethic of your profession: that every life is of equal worth (even the lives of those who deny that tenet), that nobody should come to unnecessary harm owing to a caregiver’s decision.
The reason you can discharge someone who poses a serious threat of violence to others in the facility is, roughly, that if we face a choice between seriously endangering Jamie and seriously endangering Alex, and Jamie is the source of the danger to Alex, we should prefer the threatened person to the threatener. We’re essentially choosing between bad medical outcomes; in a clinical setting, knives should be wielded only by surgeons. That wasn’t the situation you faced. Hate speech produces what some legal scholars would deem a “dignitary affront”; and a dignitary affront, however much we deplore it, is not a medical crisis. Your primary brief wasn’t to calibrate the harms done by hate speech to the climate of your workplace. It was to ensure your patient received appropriate care, whether in your hands or others’.
Let me note, too, that the freight of words is affected by who’s speaking them. Patients — perhaps as a result of sepsis-associated delirium or certain neurological disorders — may not be in control of their speech; people who are subject to Tourette-syndrome-related coprolalia should not be denied medical treatment because their words make clinicians uncomfortable. And your patient? She had a problem with substance use and employed language that is, increasingly, stigmatizing of the user. She had no power over the clinicians who attended to her and to whose decisions she was subject. One indication of her lack of status is that your hospital’s risk managers evidently decided that the institution could safely eject her without being held accountable for the consequences. Though they didn’t intend to mete out a punishment that might have amounted to a death sentence, the risk managers effectively put the hospital ahead of the patient.
The duties of medical professionals are demanding. In wartime, a medic can have the responsibility of saving the life of a wounded enemy soldier, even if the soldier has just killed one of that medic’s friends. The fundamental clinical imperatives — evolved, collectively, over generations — shouldn’t be hastily set aside. Clinicians have duties of care to patients, even odious ones. And the more serious the likely consequences of refusing care, the larger the burdens they should be willing to accept.