Goutam Gutta
What is an ethical institutional response to patient requests for clinicians of a specific race?
Healthcare institutions hold important ethical obligations towards their employees and their patients. These institutions are stewards of the physician-patient relationship and, as such, must ensure that both physicians and patients are well-supported. Additionally, physicians hold important ethical obligations towards their patients and receive extensive training to help support these obligations. However, the opposite is not necessarily true. Patients hold fewer ethical obligations towards their physicians and healthcare institutions outside of those that dictate typical interpersonal relations. This imbalance is evidenced by the greater permissibility of a patient requesting a physician of a specific race and not vice versa. Given their aforementioned ethical responsibilities, healthcare institutions must mediate this imbalanced relationship while ensuring that both physicians and patients receive the support they need. The question, of course, is how. An effective approach would be to articulate the ethical responsibilities healthcare institutions, physicians, and patients have towards one another and then consider the logistics of patient-physician racial concordance.
Ultimately, healthcare institutions are employers while physicians are employees. As such, there are a set of principles that dictate professionalism in this relationship, as dictated by the U.S. Equal Employment Opportunity Commission (EEOC). The EEOC dictates that permitting "...employment discrimination based on race, color…or national origin" is prohibited under Title VII of the Civil Rights Act of 1964 (U.S. Equal Employment Opportunity Commission, n.d.). From an ethical standpoint, the EEOC's legal guidelines are an application of the ethical principle of 'distributive justice.' 'Distributive justice' is defined as the degree to which "... society's institutions ensure that benefits and burdens are distributed among society's members in ways that are fair and just" (Velasquez et al., 2014).
On the other hand, the ethical responsibilities that healthcare institutions have for patients are essentially the same as the medical ethical responsibilities that physicians have for patients. These four chief principles are (1) respect for autonomy, (2) beneficence, (3) non-maleficence, and (4) justice. These ethical principles help guide physicians' clinical counsel and reinforce patients' rights to navigate this counsel and select a treatment plan (Stanford University, n.d.). Suppose patients do not agree with a physician's proposed set of treatment options. In that case, they, under the ethical principle of autonomy, have the right to step back and choose another physician who may propose a different set of treatment options. Patients could easily choose a physician for themselves based on race if so desired during this search process. However, the four ethical principles do not outline the patient's ability to explicitly request a healthcare institution for a physician based on race.
Furthermore, even if healthcare institutions granted patients the ability to choose a physician based on race, they likely would not be able to do so sustainably or ethically. While it is logistically feasible (and even probable) for White patients to have a White physician because around 56% of physicians are White, the same is not the case for African American and Latino patients (AAMC 2019). As of 2018, only 5% of physicians are African American, and only 5.8% are Latino (AAMC 2019). However, a 2004 study found that 22% of African American patients and around 33% of Latino patients preferred physicians of a concordant race (Chen et al. 2005, 138). This disparity is striking. If healthcare institutions permit patients to request specific physicians on the basis of race, the comparatively few physicians of color will need to treat an increased volume of patients resulting in a distinct imbalance of workload.
As mentioned previously, healthcare institutions have an ethical responsibility to prevent variations in physicians' workload based on race under the ethical principle of 'distributive justice.' However, these institutions do not have an ethical obligation to grant patient requests for physicians of a specific race under the four principal medical ethics. If healthcare institutions decide to permit patients to request a physician of a specific race regardless, they may create an imbalanced work environment that violates the ethical principle of 'distributive justice.' Therefore, until the racial distribution of physicians more closely resembles the racial distribution of our nation, I find that it would not be ethical for healthcare institutions to permit patients to request a physician of a specific race.
Counterargument and response
A 2020 health policy survey-based study found that physician-patient racial concordance resulted in an improved patient experience (Takeshita et al. 2020). Given this study's findings and the significant health inequities experienced by Black, Hispanic, Native American, and immigrant patients, it may be argued that healthcare institutions should grant patient requests for physicians of a specific race. After all, enabling patients to request physicians of a specific, concordant race could allow patients to utilize their autonomy to seek better health outcomes and move closer to the medical ethical ideal of 'justice.'
While it would certainly be ideal to empower marginalized communities to receive the care that they greatly deserve and to pursue established ethical ideals, doing so in this manner is currently not very utilitarian. Given the stark minority of physicians of color, enabling patients to choose physicians of the concordant race would significantly increase the workload of physicians of color. An increase in workload naturally means that these physicians would need to spend less time with each of their patients, lessening the quality of care they can provide. From a utilitarian standpoint, this is not ideal. From the perspective of a healthcare institution, permitting this decrease in quality of care would violate the ethical principle of beneficence which seeks to maintain a net benefit for all patients.
Until the American healthcare system cultivates a body of physicians proportional to the size and racial diversity of the population, I believe that it would be unethical and unsustainable to permit patients to request physicians based on race. There is still much work for us to do.
References
- AAMC. 2019. “Figure 18. Percentage of all active physicians by race/ethnicity, 2018.” AAMC. https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018.
- Chen, Frederick M., George E. Fryer, Robert L. Phillips, Elisabeth Wilson, and Donald E. Pathman. 2005. “Patients’ Beliefs About Racism, Preferences for Physician Race, and Satisfaction With Care.” The Annals of Family Medicine 3, no. 2 (March): 138-143. https://doi.org/10.1370/afm.282.
- Stanford University. n.d. “What are the Basic Principles of Medical Ethics?” Medical Ethics 101. Accessed January 29, 2022. https://web.stanford.edu/class/siw198q/websites/reprotech/New%20Ways%20of%20Making%20Babies/EthicVoc.htm.
- U.S. Equal Employment Opportunity Commission. n.d. “Prohibited Employment Policies/Practices.” US Equal Employment Opportunity Commission. Accessed January 28, 2022. https://www.eeoc.gov/prohibited-employment-policiespractices.
- Velasquez, Manuel, Claire Andre, Thomas Shanks, S. J, and Michael J. Meyer. 2014. “Justice and Fairness - Markkula Center for Applied Ethics.” Santa Clara University. https://www.scu.edu/ethics/ethics-resources/ethical-decision-making/justice-and-fairness/