Bioethics Discussion Blog: February 2006





Saturday, February 25, 2006

Legislation in Virginia to Prevent Physicians Asking About Household Guns

From The Virginian-Pilot on February 23,2006,

A pediatrician who asks a child's parent about firearms in their home could lose his or her license or be disciplined under legislation being considered by a [Virginia ]Senate committee today.
The bill would prohibit health care professionals from asking a patient about gun possession, ownership or storage unless the patient is being treated for an injury related to guns or asks for safety counseling about them.

The bill was passed in the Virginia state lower legislative chamber last week 88 to 11. The article continues:

The legislation is opposed by The Virginia Chapter of the American Academy of Pediatrics because it blocks a common practice by medical professionals to inquire about gun ownership and safety when they go over a safety checklist with parents during a child's regular checkups from birth to puberty. ?
The National Rifle Association supports the bill because it will protect gun owners "from intrusive, unnecessary questions from medical professionals," according to the NRA Institute for Legislative Action Web site.

Here is my response to this likely unconstitutional (denial of free speech) but also irrational political action:

I think that the Virginia bill represents either meddling into the practice of medicine for the legislator's
own personal political benefit or that they are totally unaware about the process or value of medical history taking as practiced by physicians and as responded to by patients. Physicians take a medical history, both a present illness and past history to attempt to get facts that may or may not be immediately useful in making a diagnosis or in teaching the patient about health matters. The past history may include a variety of psycho-social questions and other questions including questions about understanding about risks for physical injury including controlling those risks. These may include not wearing helmets, not using seat belts, using ilicit drugs, sexual behavior, unlocked medicine cabinets accessible to children and risky management of guns in the household. These are only what the physician believes are pertinent questions for the patient to answer if the patient wishes to. Note that the responses are not made under oath. Patients may refuse to answer or may provide an answer to the physician that is inaccurate or intentionally a lie. But for the physician to be punished simply for asking a question that could in the individual case have profound significance ("oh, I keep my loaded gun under my bed so I will be ready for an intruder at night!") is beyond rational belief regardless of what the general risk statistics show and represents irrational lawmaking. Do the legislators know that at my medical school we actually teach our students to ask the patient about the number of individuals the patient has had sex with over their lifetime, whether with men, women or both, about sexual practices and more sensitive questions? Some argue that physicians should not lecture to patients about issues in medicine that have not been proven by research study. However, physicians often deal with issues that have not been statistically studied with regard to pertinence to a specific outcome but possibly may be of great physical/psychologic and social importance to the life of the individual patient. I think we should all face the fact that what physician advise or carry out is not all evidence-based medicine and often we may end up saying and doing what we think is the best for the patient in our own judgment based on our knowledge and experience. Now I will get off my soap box and will be eager to read what my visitors think. ..Maurice.

FOLLOWUP: In yesterday’s news comes the word that the Virginia Senate Education and Health committee voted down legislation that would have made it unlawful to routinely ask patients about firearms.

Friday, February 24, 2006

More on Racial Preferences of Patients for Caregivers

Continuing with the discussion of the racial preferences of patients for their caregivers, a study by Rachel L. Johnson and others in the Journal of General Internal Medicine, vol 19, number 2, 2004 shows that non-white groups have their own concerns regarding how they might be treated by those of a different culture or ethnicity. In that study consisting of 6,299 white, African-American, Hispanic, and Asian adults of which 54.3 percent responded to the telephone survey, the following statistically significant results were described. African-Americans, Hispanics and Asians, more likely than whites, agreed that they would have received better medical care if they belonged to a different race/ethnic group. They agreed that the medical staff judged them unfairly or treated them with disrespect based on race/ethnicity and also agreed that how they were treated was based on how well they spoke English. This study might provide some understanding why non-white groups might want to have a physician who is of their culture or ethnicity to care for them. It also might add weight to the need for all physicians along with their offices and hospitals to be culturally educated and sensitive in the professional relationship with their patients. ..Maurice.

Tuesday, February 21, 2006

Ethical?: Requesting Racial Preference of Caregiver

This issue has been on my bioethics website (now inactive) for years and I have received so many enlightening responses that I wanted to share them with my visitors to this blog. Further comments and experiences from my current visitors are greatly welcomed. ..Maurice.

Complying with Patient's Request Regarding Racial Preference

Of the many ethical issues that health care organizations are now beginning to consider how best to resolve, the following senario regarding the patient's racial preferences can be a difficult one. A case manager is arranging home care for an elderly European American man who is about to be discharged from the hospital. The services at home will be provided by a home health agency which has uniformly served the newly discharged hospital patients well with excellent care. After much discussion about the man's medical needs when he gets home, the patient abruptly made a request. He stated that he did not want anyone who was black to come into his home. He stated he doesn't feel comfortable around black people and that he especially does not like the idea of a black person walking around in his house. "I'm a strong believer in staying with your own kind. Besides," he continued, "I have a right to decide who comes into the privacy of my own home." The case manager now has to decide whether to make arrangements to specify a white worker or to tell the patient that the home health care providers will not comply with his request. Should the racial preferences or prejudices of the patient be taken into consideration? Is it ethical to do so considering the very competent black employees on the agency's staff and is it fair to them? Should health care institutions comply with a patient's request for racial preferences in care?


Date: Mon, Mar 8, 2004 4:12 PM From: To:
Operating under the premise that the patient is always right, i think that he has a legitimate right to make the request that the healthcare workers coming into his home be Caucasian only. However, I would have to make it clear to this gentleman that it is not our policy to base the needs of our homecare patients on race alone. In case of emergency, would he refuse the assistance of a Black or Hispanic aide, or even possibly a Paramedic? This patient might feel that he has valid reasons for his decision. Perhaps, a family member or friend was robbed, murdered, or raped by a minority and he does not feel safe. Although it is unfair to judge an entire group by the wrongful actions of one, it is nonetheless his feeling and as such, must be respected. If my agency was supplying homecare to a Native American who held strong to his tribal beliefs, i would make an attempt to meet his needs by attempting to pair him with a Native American home health nurse with similar beliefs or at least an understanding of the culture. I would also try to meet the spiritual needs of an Orthodox Jew if I employed a nurse who would enjoy caring for that patient and the arrangement was satisfactory to both. We can talk about cultural diversity until we're blue in the face, but the actual implementation of it is another matter. Aren't the above examples of accepting the cultural and religious diversity of our clients? Why should this man's opinions be valued any less? It is not our duty to judge him. It is our responsibilty to assist him to his highest level of independence.

Date: Thu, Dec 4, 2003 7:22 PM From: To:
Another scenario may shed some light on this situation. This is an actual event and response.
The local police and fire department offered to the community programs geared towards fire and crime prevention. The city had established a rotating roster of qualified personnel.
A local large Christian (Baptist) church sent letter to the city manager requesting fire and crime prevention presentations. The closing paragraph stipulated that no females of blacks were to be included among the presenters.
The city manager discussed with city council members. Unanimous opinion was to accept the invitation and to note that all participants were qualified and those assigned to the detail on the chosen day would be the presenters.
The church never responded.
I feel the individual has right to specify whatever terms he wishes. The agency is under no obligation to honor his requests and should so state. To accede to his demands perpetuates a destructive system and demeans employees who are excluded not to mention the lost income potential and the potential for employers to return to the bygone era of hiring on the basis of skin color.
The patient is free to search for someone to honor his requests and must accept the consequences of his choices.
BTW , I am a physician who chaired hospital ethics committee for many years in the above community

Date: Tue, Oct 7, 2003 1:51 PM From: To:
The patient should be able to rely on statistical data - just as the US Sup. Ct. did in Brown v. Board of Ed. or Duke Power Co. - If the percentage of thefts from individual homes by certain groups rises above a statistically significant number - the patient should be able to bar that group from home health care without any more said about it.

Date: Wed, Apr 23, 2003 6:52 PM From: To:
A few years ago, as a home health nurse, I was faced with this same dilemma..only the patient also did not want anyone who smoked in the house. I wrestled with this and the decision that I came up with was that the patient had the right to say who and who did not come into his home. Not only was I concerned about the rights of the patient, but als caregiver. I would never have sent someone into his home that I knew would not be welcomed. As it happened, one day his caregiver got sick, and was unable to make a visit . The only caregiver that I had available was a black aide that smoked. I called him and explained the situation, giving him the option. He opted not to have anyone come that day. He later thanked me for letting him make the decision instead of forcing a situation on him that he wouldn't have been happy about. I think that every effort should be made to make the patient happy, within reason of course. After all, most of the time, they are paying the bill---in some way or the other (Medicare, private insurance, privatge pay, etc.)

Date: Tue, Mar 25, 2003 10:57 AM From: To:
If this would have been a black patient requesting that only black workers be assigned to his case, would we consider it so unusual? I am an RN in the BSN program at Cal State Univ, Dominguez Hills and I have recently been doing clinicals in a home health agency here in Southern California. I am white, yet I don't find it unusual for Hispanic clients to want only Hispanic workers at their homes, or black individuals to prefer only black individuals in their homes. We don't make a big deal out of it. I think just because a white person prefers only white workers at his home, there is no greater indication to make a big deal out of it than in the other cases I have mentioned. After all, we have Black Nurses Associations, Asian Nurses Associations, etc. Would there be a big deal made if we formed a White Nurses Association? If so, why? At my school there is a Black Nurses Union and an Asian Nurses Union. What if I were to suggest a White Nurses Union? Why would I be thought of a prejudiced? Would I be welcome into the Black Nurses Union? Why not? I think the old man in this case should be allowed, without question to havehis "white only" workers as he is requesting. He did give justifiable reasonsand to often it is hard to change the minds of these old folks. They wereraised that way and it is harder for old dogs to learn new tricks.
Inge Kriegler, Tujunga, CA

Date: Sat, Nov 10, 2001 11:58 AM From: To:
The patient has a right to voice his concerns, he also has the right to stipulate the culture he would like in his home. But coarsen around this matter may have to be looked into, what has happened in the past, why this patient is reacting like this. Don't only look at the little picture, the big picture has to be taken into consideration.

DateL Fri, Jan 19, 2001 10:36 PM From: To:
I am not so much concerned about the preferences of the patient, since they are predjudicial in nature. However, my concern would be for the caretaker that would be sent into this person's home. I do not feel that it would be fair to send an African-American into this obviously prejudiced environment. He/She deserves much more respect than that.

Date: Fri, Aug 11, 2000 11:44 AM From: To:
If he is paying out of pocket, he has the right to hire whomever he likes. If the Federal Government, through Medicare or Medicaid is paying for his home services he should not be able to stipulate the race of his home health aid or visiting nurse.

Date: Fri, Feb 19, 1999 2:43 AM From: To:
Quality Care and the Wounds of Diversity
Kenneth Kipnis, Ph.D. Department of Philosophy University of Hawaii at Manoa Honolulu, HI 96822
Since 1982 I have done ethics consultation at a number of hospitals in the state of Hawaii. Uniquely separate from the Mainland, situated in an isolated part of the Mid-Pacific, many of us who have been transplanted here find ourselves developing something of a planetary perspective. Heretofore accustomed to being a majority, Caucasians like myself represent only about a third of the population. There are about as many Japanese-Americans. The balance is a cosmopolitan blend of Chinese, Filipinos, Hawaiians, Samoans, Koreans, Puerto Ricans, Native Americans, African-Americans and other groups. About 40% of our current marriages are interracial and all of us are minorities. It is an unusual place to be doing ethics.
Several years ago I was called to a hospital to assist in a case involving an older Korean gentleman. He had had a difficult medical condition -- hard to diagnose and treat -- and had steadily gotten worse despite the vigorous efforts of the medical and nursing staffs. At last the doctors had felt they knew what the problem was and offered the patient a treatment plan that promised a better than 50% chance of recovery with only minimal risks. Nonetheless the patient had refused further treatment. He said that, having suffered enough already, he did not want the doctors to do anything else. Though there had been an earlier history of mental illness, there was no evidence that it was playing any role in this refusal. He had understood his options as these had been explained and had appreciated the consequences of his choice. This refusal was properly charted and the staff awaited the expected terminal trajectory.
Had nothing else occurred, I would not have been called in and the Korean patient would likely have expired as expected. But when he was asked the hospital's routine questions about code status, his request for full support generated the call for an ethics consult. Following a telephone conversation with the patient's attending physician, I went to the bedside and joined up with a hospital ethics consultant, a very experienced nurse who had just finished reviewing his chart. The task for the two of us was to understand the glaring discrepancy between his informed refusal of potentially life-saving treatment and his firm request for cardioversion if he went into arrest. The latter was a burdensome procedure that could prolong his life for only a brief interval. Why was he rejecting the promising treatment but requesting the code? What was making the difference for him?
For at least 40 minutes the two of us conversed with the patient, questioned him, gently pressed him, and still the discrepancy remained opaque. Finally, perhaps caving in to our persistence, he quietly asked if we would mind if he said something embarrassing. We encouraged him to go on. In the most timorous of voices, the Korean gentleman asked if we had noticed that all of his doctors had been Japanese?
I was stunned by an instantaneous appreciation of what was going on. For most of the first half of the 20th century, Imperial Japan had ruthlessly tyrannized Korea much as Nazi Germany had oppressed Poland during World War II. Exploited as inferiors, many Koreans still retain powerful anti-Japanese sentiments. This unfortunate man perceived himself as exquisitely vulnerable, surrounded by his too-familiar oppressors.
As it happened, neither of us at the bedside had noticed that the gentleman's doctors had been Japanese. The physician I had spoken with on the telephone was a woman with an unexceptional accent and a non-Japanese last name. The nurse working with me had never met her. We did, however, know enough recent Korean-Japanese history to appreciate the patient's concerns. He "knew" why he kept getting worse. The Japanese doctors were not trying to make him better. What we were seeing as failures to improve, he saw as successful attempts to cause his death. To make things even worse, he was familiar enough with Western ideals of toleration, equality, and individualism to know that, in Hawaii, it was improper to offer his candid opinion of Japanese physicians. There was a cryptic note in the chart that he had once asked a nurse if he could have a doctor in a three-piece suit. He had noticed, we later learned, that while Japanese doctors on the unit wore white coats, many of the others wore three-piece suits. When this ploy failed, he had then tried to evade the deadly ministrations of his Japanese physicians by refusing their offers of treatment. Of course he would want a prompt emergency response if he went into an immediately life-threatening condition. After all, he wanted to live. Paradoxically, he was refusing life-saving treatment in order to save his life.
Clearly the patient needed to see a non-Japanese physician. The nurse-ethicist relayed our findings to a very cooperative attending who readily agreed with our recommendation. Within a few hours another doctor -- a non-Japanese physician wearing a three-piece suit -- was at the bedside persuading the patient to accept treatment.
In the years since, I have often reflected on what happened that afternoon. On many occasions I have recounted the story to medical and nursing students and to clinical staff. I have used the case to show that ethics consultation can be critically important in patient care. Here was an instance in which a patient's life may have been saved by an ethics consult. I have used it to illustrate the importance of understanding the patient's underlying value commitments. There are times when our job isn't done until the patient's decision makes sense against the background of the patient's reasonably stable personal values. Here the two of us kept up the questioning until the patient's process of decision came into focus. In retrospect it was critically important that we took the time we needed. And I have used the case to illustrate the importance of understanding cultural differences. Perhaps the two of us -- and the hospital staff as well -- should have been more appreciative of Korean cultural sensibilities.
But more recently I have been troubled by another aspect of this case.
The history of the United States can easily be read as a dramatic succession of cultural collisions. From the prototypical "Columbian encounter," to the expansion into lands occupied by Native Americans, to our social and political responses to race-based slavery, and up to our current divisions around immigration and affirmative action, we have wrestled mightily with the painful legacies -- the wounds -- of cultural diversity. While much of this history is unbecoming, there is some credit we can take for the progress that has been made in overcoming prejudice and eliminating discrimination. Schools that formerly barred the entry of women and minority groups now strive for diversity. Social institutions now commonly express and often honor their commitments to nondiscrimination. Prejudicial slurs and racial stereotypes, when they are advanced, are frequently challenged. These familiar features of American life are new. For many -- perhaps most of us -- they are welcome.
Even so, clinicians still see patients who demand accommodation on the basis of racist beliefs and attitudes. Prejudice and stereotypical thinking patterns may be dominating a patient's preferences when, for example, a Southern white male in an emergency room refuses to be treated by a black resident, or a Vietnam veteran objects to being attended by a Southeast Asian doctor. While, on the one hand, clinicians have a professional concern to help make the patient comfortable, that value can be in conflict both with the civic obligation to refrain from becoming an instrument of invidious discrimination and the collegial obligation to stand up for the professional dignity of one's colleagues.
What has bothered me about my role in the case of the Korean gentleman was that, until recently, those aspects of the case had completely escaped my attention. Notwithstanding the history of Japan and Korea during the first half of the 20th Century, I had no reason to believe that physicians of Japanese ancestry, currently practicing in Hawaii, had it in for their Korean patients. Both the nurse-ethicist and I viewed the gentleman's misgivings as wholly baseless. Although we did not discuss the matter with the patient (as perhaps we should have), we took it for granted that even though Japanese occupation forces had historically mistreated Korean nationals, it did not follow that Japanese doctors in Hawaii were now mistreating Korean patients. Yet instead of challenging the patient's beliefs on the basis of our own experience, the two of us left them unquestioned. Not only that: despite the absence of any reason to doubt the fidelity and honor of the gentleman's Japanese physician, we successfully effected her withdrawal in keeping with what we believed to be the patient's baseless prejudices. Was it right for us to do this? If it was, when is it appropriate to accommodate patient prejudice and when is it not?
One route might be to distinguish between prejudicial beliefs that are the consequence of past victimization and those that emerge purely as an integral aspect of the processes of oppression. It seems easy to sympathize with a Jewish survivor of the Nazi concentration camps who is severely distressed at the prospect of being treated by a German physician. It seems difficult to sympathize with an anti-Semitic skinhead who does not want to be seen or touched by a Jewish physician. In similar fashion, one might suppose that the Korean gentleman's sentiments are grounded in his painful memories of the brutal Japanese occupation and, with that pedigree, perhaps worthy of accommodation. But the Vietnam veteran's objection to treatment by a Southeast Asian points up the difficulty with this approach. Is the veteran a victim or an oppressor? Strong cases might be made both ways. Without in the least diminishing the seriousness of the damage they may do, racists themselves may lead profoundly diminished lives, spiritually and socially crippled by the attitudes they have absorbed. Alas, the world does not divide neatly into victims and oppressors; and, accordingly, a refusal to accommodate a prejudice-based preference may merely reflect the limits of our moral imagination.
At least one colleague has asked me whether I knew -- really knew -- that the Japanese physicians were not trying to harm the Korean patient. In related discussions I have encountered vigorous disagreement about whether women who routinely ask for female gynecologists are merely prejudiced against men or merely knowledgeable about the relative merits of women. Although there was agreement in that debate that some male ob-gyns were sensitive and considerate and some female ob-gyns were not, there appeared also to be consensus (among those in a position to know) that female ob-gyns were a better bet. Is this a prejudice or not? Having never been a Korean patient of a Japanese physician (or, for that matter, a female patient of an ob-gyn), my experience is an inferior source of data. Perhaps on this basis, we should routinely defer to patient preferences. Maybe they know something we do not.
On the other hand, these preferences are very like those that have historically created institutionalized practices of sexism and racism. Until the 1960's many American owners of hotels and restaurants assumed -- perhaps reasonably -- that white customers would not want to dine and lodge with black customers. The presence of widespread prejudice can have the result of excluding stigmatized groups from careers and opportunities that are routinely open to others. Perhaps the distinction between accommodatable and unaccommodatable prejudice turns on the severity of the cumulative effects of accommodation. The Japanese doctors working at the hospital were not, it seemed, suffering discernable losses as a consequence of Korean prejudice. For all I know, my case may have been unique. However the historically broad reticence among white patients to accept the ministrations of black physicians may have contributed to unjust exclusionary practices. We may be better off as a consequence of holding that the preferences of others cannot be used to justify hiring on the basis of sex or race. Notwithstanding male modesty, female sports reporters now have equal access to men's locker rooms. The societal need to overcome damaging discrimination can, it seems, give us a weighty reason to refuse to accommodate prejudice-based preferences. Perhaps it is this social injustice that should properly limit accommodation.
But recollect that the Korean gentleman was existentially prepared to die rather than accept treatment by his Japanese doctor. One supposes that, besides Koreans, other groups may be equally willing to live out equally firm commitments to prejudice-based preferences. Consider for the moment only those cases in which the accommodation to prejudice-based preference does significant damage to the interests of stigmatized groups. Should HMOs, hospitals and health-care professionals be prepared to sacrifice the lives of vulnerable patients on the altar of tolerance and nondiscrimination? One can perhaps envision an institutional or professional commitment to offer high quality services, but if a vulnerable patient refuses these on the basis of a health-care professional's race, sex, religion, etc., that is the patient's choice: the death that ensues is not our responsibility.
And yet a commitment to quality care can involve a commitment to providing that care in ways that patients can accept. In these cases one cannot evade responsibility by showing that quality care was offered but refused. Responsibility seems to be there when (1) the reason the care was refused had to do with how it was offered, and (2) the care could have been offered in a way that would have led to acceptance. How do we deal with vulnerable patients whose prejudice-based existential preferences are damaging to our deepest senses of justice and human dignity? The dilemma involves a conflict between the clear duty to minister as best one can to the patient's pressing health care needs and the equally clear prohibition on becoming an instrument of injustice. Vulnerable patients with societally damaging, prejudice-based existential preferences force us to make a choice.
I confess I am not confident about how these values should be prioritized. While it is sometimes a mark of success merely to have stated a problem clearly, a few tentative suggestions can be made in closing. In the first place, it would surely be ethically prudent to try to finesse the dilemma. Perhaps the Southern white male in the ER could be persuaded to accept treatment from the black resident. And it seems that there is good reason to confront the patient directly: at a minimum to defend the capabilities and integrity of one's black colleague and to make clear for the record that one does not share the patient's opinion. Perhaps in some cases this tactic will suffice to make the problem disappear.
But if it does not and one has to choose, I believe it should be on behalf of the patient and his or her physical well-being. For it is that value that, above all, informs the practices of health care: its distinctive skills, knowledges, and technologies. Conversely, professional training programs in medical and nursing schools are not even peripherally concerned with assessing the claims of those who have been aggrieved and wounded by history. It is inevitable that health care -- like all human pursuits -- will be practiced in a profoundly imperfect world and that these imperfections will implicate practitioners and clients alike. In the face of all of these shortcomings, there is something to be said for mindfully striving to treat vulnerable patients with dignity and respect, even when their values are hateful.
Copyright 1998 Kenneth Kipnis
The author is indebted to the contributors to the Bioethics Discussion Forum at the Medical College of Wisconsin for helpful and illuminating commentary on some of the issues raised by this case. An earlier version of this piece appeared in Clinical Ethics Report, Fall/Winter, 1996, pp. 5-8.

Date: Wed, Feb 17, 1999 10:57 AM From: WSHIRK@AHERF.EDU To:
I found this case interesting, and used it as a basis for a class presentation in a graduate program in health care ethics. Here is my analysis based on the Jonsen/Siegler/Winslade model
Moral/Ethical Issues
In this case, the patient*s physical health is not at issue, but rather the patient*s preference regarding the delivery of his health care. Surely in most instances, racial prejudice should not be tolerated, and in this case, one might be tempted by the patient*s apparent bigotry and one*s own political correctness to deny his request, to lecture and censure him, and to suggest that if he cannot countenance a black nurse that he should seek another agency to perform his care. There is a temptation, in other words, to consider the patient*s preference to be improper, and therefore not to be seriously considered, or rejected out of hand. Or, should we view this patient more holistically, and allow that his culturally or religiously based feelings and ideas are a part of the whole picture that must be considered in his care?
Is this also a marketing issue: should this patient be forced to accept a product that he does not want? It is also a social issue: should a social agenda (i.e. race relations/equal opportunity) be superimposed on a health care plan? It is an emotional issue: are we professional enough to set our own personal feelings aside to care for those whose views may be abhorrent to us?
Medical Indications/Goals of Medicine
The patient*s unspecified medical problem is in resolution, and appropriate follow-on care has been arranged by the home health care agency. While the patient*s racial feelings may present a barrier to completion or success of the health care plan, this harm can easily be avoided through selective staffing.
Patient Preferences
The patient requests that he be cared for by his *own kind.* This is expressed in terms of phobia rather than hatred: he *doesn*t feel comfortable* around black people. He also expresses a concern for what might be called *freedom of association*; that persons possess a natural right to associate with other persons of their own choosing. The patient states, *I have a right to decide who comes into the privacy of my own home.* There can be no doubt, whatever the reason, of the validity of this claim to privacy. To violate his sense of his own rights would be to cause him harm. (These issues overlap contextual features.)
Quality of Life
The patient*s baseline QOL is normal. It is expected that home health care will expedite and return him to, or maintain him close to normal functioning. His quality of life will be impacted negatively if the HHA refuses to honor his racial choice of provider, or if the HHA chooses not to take his case because of his request.
Contextual Features
There may be legal issues: can black employees claim discrimination if the agency takes *no blacks allowed* cases, or honors otherwise racially motivated requests from patients? Can the patient claim harm if he is forced to accept black care givers, if for any reason his health declines, or if the HHA declines to provide care under his conditions? Can the HHA legally specify race in case assignments?
There may be religious factors, the patient stating *a strong belief* in the separation of races. Should not a patient*s belief system, however foreign to our own, if it causes no harm to the patient be respected?
There is the provider issue: should not the HHA, acting as the employee of the patient, provide the patient/customer with the product he desires?
Case Consultation Note:
The patient*s racial prejudice cannot be treated medically, but it cannot be ignored; in this case, it is as much a part of the patient*s medical indications as his blood type, and must be taken into account and dealt with in a way that benefits the patient, and promotes his healing. His racial views might be analogous to an allergy to a certain medication, that we are aware of and should and can easily avoid. Our own feelings, as in any case, should be set aside.
It is not the purpose of a health care plan to change the patient*s religious or cultural views, or to advance one*s own social agenda. We might hope that some day, he might come to a more mature and reasoning understanding, but that is not our responsibility. The best we can do for him is treat his medical condition in the way which most benefits him.
The fundamental goals of medicine and the patient*s quality of life seem to favor granting his request for care givers of his own race.
WHS 02-17-99

Date: Wed, Feb 10, 1999 4:56 PM From: To:
People have told me many times that differences in race don't mean anything, that the only difference between a black person and a white person is the color of their skin. When I use reason it makes sense, people are all made of the same ingredients. But race means an awful lot to most people. The one thing that I think is constant across all cultures and all races is the capacity to hate and to quickly categorize or classify someone by their physical appearance. So race means a lot to this man. The priority of the organization thats caring for him is to do just that, anything they possibly can to heal him. There really isn't any time or energy to waste on caring whether an employee is going to be offended by this patient's racism. The organization needs to worry about what they can do to care for their patient. If he doesn't want a black man in his house then give him the boot. The organization needs to find another system of health care that can care for his personal needs. They need to find him another organization that has the patience to deal with his racism. Denying him a white doctor is definitely a waste of time. The patient needs an environment in which he can be comfortable so he can heal. Give him this environment by sending him along to the next clinic.

Date: Thu, Jan 28, 1999 7:38 PM From: To:
Something like that happened in my home state of Michigan. A patient at a hospital said that he didn't want any black workers entering his room. (He told this to a white nurse) In turn, the nurse put a sign outside of the door saying no blacks allowed. Of course the we were offended by this because the nurse went about it the wrong way and didn't ask assistance from administration in this matter.
She resigned before she could be fired.
As for the patient...who cares!

Date: Tue, Jan 12, 1999 6:05 PM From: To:
I am the owner of a HHA. Our policy is to clearly state that we are not permitted to discuss race when a client makes this request. Sometimes the client goes elsewhere, but an employer has an ethical obligation to employees, too. I believe the patient has the right to make any decisions about his care , but the provider must operate legally and ethically.

Date: Mon, Oct 26, 1998 12:34 PM From: To:
I believe that the health care institutions should comply with the patient's request to not allow any black person in his home. Even though I have no problem with that racial group, I do believe that every person has their right to pertake of the company of who they please. People have put a stereotype on the black community, and it has labeled everyone of that race. Just because of a few ignorant blacks, the whole race is faced with the hate of many. I also think that the predjudices of the patient should be taken into consideration. We all have our opinion, heck, that's what makes the world go round. Eventhough it's not ethical to the black employees on the agency's staff, the man is paying their salary. If someone was paying my salary, I would do what they asked. It's not a matter of fair or unfair either, it's what everyone agrees on. The board who runs the elderly home should sit down and take a vote. The winner of the vote, gets their way. They should consider the rights of both parties.(The man and the black workers) They should follow the constitution and protect both parties as well.

Date: Wed, Sep 23, 1998 1:26 PM From: To:
At first glance maybe the patient wishes should be accepted. However, I believe a larger societal ethical issue applies. To comply degrades the value of and worth of minority employees to society, their profession, and to the employer. The employer may seek to rid him/herself ofsuch employees.
Charles M Davis, MD

Date: Fri, May 22, 1998 4:30 AM From: To:
If an individual is paying for the care, they should be able to select whom ever they desire and feel comfortable. If they are not paying for the care then they should receive what is free and available.

Date: Fri, May 8, 1998 5:42 PM From: To:
This is an immediate response, but the issue you pose is similar to one which I have heard discussed at a conference in which an extremely old and prejudiced woman was refusing care offered by a very young and sensitive Cambodian nurse on the grounds that she thought the young woman did not belong in the US and should go back where she came from. In this case the director of the nursing home told the Cambodian nurse that she should proceed to the next patient and only return when she was assured that she would not be met with prejudice. The director then calmly took the old woman (who though racist was not in general demented) through a graphic description of the horrors that this young woman had lived through during the regime of Pol Pot, and the nobility of spirit that other patients recognized in this nurse. Having established a bond of sympathy, the director finished by describing the excellent care that this nurse provides, and the loving atmosphere she fosters, and the importance of this young nurse to the rest of the staff After this, the director asked the patient whether she thought she would like to welcome the nurses ministrations in the loving spirit in which they were offered or whether the director should begin to seek private nursing during the shift of this nurse since no other nurse would be provided. The director also offered to have counselling provided if the patient wished. Accepting the factors invoked, this patient thereafter accepted "care" from her designated provider. Whether she continued to harbor internal racism and just made one exception or whether she began to overcome her initial racist stereotypes is unknown to me. To give in to "The consumer won't purchase from X because of racism" is to prolong racism in employment. I would follow the lead of the nursing home director and offer to let this patient seek his own private care, interviewing whom he will, or accept the provision of attested excellence, and be aware that his provider has already suffered from racism and has much to bear as he.

Date: Mon, Dec 15, 1997 5:20 PM From: To:
Inorder to resolve the ethical problem created by the patient's request, I would ask the following questions: what is the motive for the request, does it harm other people, and does it harm the person requesting it. The request to exclude any black person to provide care in the client's home, appears to be motivated out of a fear that is not based on reality, would do harm to the black person's involved, and would continue to harm the client, by supporting an illusion. Based on these factors, the request for home health care with racial preferences by the patient, would be denied.

Date: Tue, Sep 2, 1997 4:28 AM From: (audreye) To:
Dear DoktorMo: Having been faced with this problem in home health care, I can say how we solved our issues relating to a client who specified racial preferences. A nurse from our home health agency (HHA) visited the proposed client in the hospital. During the visit the nurse reviewed policies and procedures related to the assignment of employees to cases as well as did a complete assessment of the client including close family and friends.
The proposed client was told that the HHA was an EEO employer and thus unable to guarantee every visit would have an employee of his racial preference. Employees were also assigned cases related to specific skills and geographical areas. The proposed client was advised that the HHA would try to honor his request without any guarantees.
The case manager said this is what he had been told by all of the other HHA's, too! As it turned out we were the last HHA on preferred list. The proposed client had to choose one of the HHA's as his hospital medicare days were ended and he was to be discharged.
My HHA ended up with this case. An emergency supervisory meeting was called and information from the visit was related to the administrator, director of nurses and nursing supervisor. The supervisor then discussed the case with her nurses. Nurses were allowed to say yes or no to case acceptance.
The client appeared satisfied as the preferred nurse was the primary nurse with others filling when necessary. The preferred nurse was only absent twice during the case. The client did not complain and the nurse filling in for those two times said he was polite.
Thank you for the opportunity to respond to your dilemma.

The Anesthesiologists Opt Out: Where is the Medical Board?

From Associated Press this morning:
SAN QUENTIN, Calif. (Feb. 21) - The planned execution of a man convicted of raping and murdering a 17-year-old girl was delayed until Tuesday night after two anesthesiologists refused to participate because of ethical concerns.

My question: Where was our California Medical Board in this whole issue? If they are our guardians of medical practice, shouldn't the Board have made a formal statement about the role of a California physician participating in an execution as currently requested for the two anesthesiologists? ..Maurice.

Friday, February 17, 2006

Court Order: Toward a Painless Execution

After receiving the order of a Federal Judge that the execution, by lethal injection, of death row inmate Michael Morales on Februrary 21, 2006 be carried out with an anesthesiologist monitoring the procedure so that the execution would be painless, the state of California found two anesthesiologists (one as standby) who agreed to attend. According to the article published yesterday in the San Francisco Chronicle,
“The judge said records of recent executions at San Quentin, including observations that inmates appeared to be breathing for as long as 12 minutes after the first drug entered their veins, suggested possible flaws in the state's procedures."

The California Medical Association (CMA), in the Internet publication, CMA Alert, responded to the order and the state’s decision as follows:

“CMA has for decades sought to end physician participation in capital punishment, including seeking legislation banning such actions by physicians and other health care professionals. ...
CMA believes that a physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not participate in legally authorized executions. Regardless of its method of delivery, capital punishment is not a medical task, it does not require medical skills and the use of a physician’s medical skills for this nonmedical task is inappropriate and a breach of one of the medical profession’s most important ethical boundaries. CMA believes that physician participation in capital punishment threatens the public’s trust of physicians. This trust is central to the physician-patient relationship.”

It is interesting that so far the California state medical board has not made public any statement regarding the professional use of physician anesthesiologists in the execution procedure. My understanding of the professional role of the anesthesiologist was to induce unconsciousness into a patient undergoing surgery, monitoring the patient during the procedure to keep the patient free of pain but still alive and without harm and then attending to awakening the patient to consciousness. It is this established responsibility that has prevented “do not resuscitate” requests by the patient being carried out in the operating room while the patient is there.

Could this involvement of the court, encouraging anesthesiologist monitoring, be a political cover toward assuring the public that death by lethal injection is not "cruel" punishment? Would the courts and the justice system be more considerate to avoid the psychic pain of an innocent person looking forward to a lethal execution. ..Maurice.

Sunday, February 12, 2006

“Good People Doing Bad Things for Good Reasons”

What is ethical or not is often in the eye of the beholder. That is why often the ethics of decisions or acts that we deal with in medicine is established through the process of consensus. And I don’t necessarily mean consensus by only scholars, lawyers or ethicists or even physicians. I think in ethical consensus the many voices of society should be included. I think that an understanding of reason for the divergent views that may occur in ethical analysis can be expressed by what Marcia Angell, former editor-in-chief of the New England Journal of Medicine has said in the past. Perhaps you have already have heard it.“Ethical violations are usually not a case of bad people doing bad things for no good reason, it is usually the case of good people doing bad things for good reasons.” If it were bad people, bad things and bad reasons, there would be no ethical conflicts. The question is whether the acts of those good people carried out for those good reasons best meet the principles of ethics for that particular issue.

Many times in clinical ethics, we find that all of the stakeholders of an issue have meritorious reasons to base their suggested actions. There also may be a meeting of an ethical principle for each action so that there is no strictly unethical violation. The problem arises when one action is inconsistent with another action and we have to decide which act and its ethics trumps another. But trumping may mean that some stakeholders may lose. Therefore, those of us who perform the responsibilities of the hospital ethics committee must remember that we are dealing with good people who have good reasons and perhaps their intended actions are not even that bad except in light of the context of the issue. One of the tools the ethics committee has in this case is compromise. Sometimes compromise mitigates the conflict if even only temporarily. Though it may be only a band-aid in making an ethical solution, it often permits time to get the parties together on a final decision.If,as an example,the issue is end-of-life decision-making and family members are in conflict as to whether enough time has elapsed, on treatment, to be assured that the patient will not recover, a compromise can be often reached. Those of us “doing ethics” should always temper our dogmatic views, if we carry them, to realize that generally we are dealing with good people and their good reasons.. and the “bad” things they may want to do is often just “relatively bad” ..Maurice.

Wednesday, February 08, 2006

On Teaching and Practicing Humanism in Medicine

What we try to teach medical students starting in their first years is the importance of a humanistic practice of medicine. For example, we teach that a patient should be considered and treated not as a disease but as a person, a human being who also has a disease. We should consider the patient's feelings and their lives beyond their differential diagnoses or lab test results. Not so long ago, my first year medical students set forth the following humanistic behavior objectives: I present them here as examples.

Treat patients as individuals, not solely as ailments. Treat patients with dignity and never speak with condescension
Pay attention to non-verbal cues and other emotional signs, being empathetic in our communications
Relay information clearly, honestly, yet appropriately to our patients
Put the interests of our patients before our own; maintain respect for the patient’s condition, views, and culture in formulating the best plan of action
Provide equality of treatment to our patients, harboring no negative bias simply on account of gender, sexual orientation, religious preference, ethnicity, mental condition, or socioeconomic status

We hope that the students will continue to remember and practice this teaching as they progress in their careers. Another look at humanism in medicine is the article from the Journal of Supportive Oncology, 2004, volume 2 number 2 titled On Medical Humanism By Celia Engel Bandman. In the article, Anatole Broyard is quoted from his essay, The Patient Examines the Doctor.

Broyard wrote, “Not every patient can be saved, but his illness may be eased by
the way the doctor responds to him—and in responding...the doctor may save
himself.…It may be necessary to give up some of his authority in exchange for his
humanity, but as old family doctors knew, this is not a bad bargain. In learning to talk to his patients, the doctor may talk himself back into loving his work. He has
little to lose and everything to gain by letting the sick man into his heart. If he does, they can share, as few others can, the wonder, terror, and exaltation of being
on the edge of being, between the natural and the supernatural.”

Without naming names, what has been your experience regarding humanistic practices in medicine? ..Maurice.

Wednesday, February 01, 2006

Second-Guessing in Medicine: Is It Ethical?

There has been a bunch of second-guessing going on about Katrina and also around the time that Ariel Sharon, Prime Minister of Israel, started bleeding in his brain. I felt it might be worth while to start a little discussion about the value and ethics of second-guessing. As for the definition, I guess there is two ways of defining it: 1) to criticize a decision or a process after the outcome is known and 2) to predict or anticipate an outcome. As examples one could question the events which man could control in Katrina and wonder whether they could have been better managed with the outcome being less disastrous. Some ask did Ariel Sharon receive improperly managed anti-coagulant therapy for his initial thrombotic stroke and was it unnecessary to perform the multiple brain surgeries with the cerebral hemorrhage? And there might be some who could answer “yes” to both examples.. but, of course, they would be “second-guessing”. What could make second-guessing improper and perhaps unethical? One factor is lack of knowledge of all the facts. Another is if it doesn't contribute to a good.

What is the role of second-guessing in medicine? Does the public, the families and the patients do it? Do the doctors do it with respect to their colleagues or do they do it with respect to themselves? I think they all do it. It is all related to trying to understand, rationalize and perhaps be able to improve on an unhappy, unacceptable and negative outcome. I think if we don’t attempt to second-guess and accept the outcome as inevitable, we will fail to find elements in the system or the person which could be improved upon. In second-guessing’s predictive sense, we are looking at the facts and anticipating something different than someone else’s predictions. Expressing this second-guessing might influence a change in the direction toward the final result. In both there approaches, second-guessing can provide a good, a benefit for this and future activities and events.

What makes second-guessing a poor behavior? When the guessing is based on belief but not on the facts. Belief can be speculation without an knowledge of details. Second-guessing without facts can lead to unfortunate and even at times damaging conclusions and actions. Accusing a doctor of malpractice simply on the basis of an unwanted outcome could be an example of second-guessing which is wrong. Calling in the President and Congress to write a law to prevent removing an unwanted tube feeding as in Schiavo is poor second-guessing.

I think that most second-guessing in medicine which in the end is valuable and good, is the second-guessing most physicians perform on themselves as they analyze their patient’s outcomes. I think physicians who don’t re-evaluate their own performance in view of the outcome of the patient’s illness have a pathologic self-confidence. That may sound rather strong. Self-confidence is great up to a point. You don’t want, as an example, a surgeon’s personal lack of self-confidence to cause a technical error because of hesitancy. On the other hand, you would want a surgeon to, in face of an unexpected bad outcome, to look at what has been done and try to find what could have been done to lead to a more successful outcome. The difference between a physician second-guessing him/herself and someone else doing the second-guessing on the outcome is that it is the physician him/herself who should know all the facts that need to be known to make an analysis. Again, second-guessing without knowing the facts is poor guessing.

Is second-guessing an issue ethical? Sure it is, if it contributes to an improvement or benefit to its various stakeholders. It is not, if it is done without factual knowledge of an issue and is aimed to be maleficent and not contribute to a good. Anyway, that is my opinion. ..Maurice.