Illustration by Louise Zergaeng PomeroyI 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 fi nd 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.
Th ankfully, 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. Th is
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 Withheld14 6.12.22 Illustration by Tomi Um
The responsibilities of clinicians should
be confi gured 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 pri-
marily 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 off ensive 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 some-
thing every employee deserves. The ques-
tion is what you should do when someone
ignores this simple moral demand. And
here your fi rst 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 some-
one 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 endan-
gering Alex, and Jamie is the source of
the danger to Alex, we should prefer
the threatened person to the threaten-
er. We’re essentially choosing between
bad medical outcomes; in a clinical set-
ting, 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
aff ront’’; and a dignitary aff ront, howev-
er much we deplore it, is not a medical
crisis. Your primary brief wasn’t to cali-
brate 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’.Can I Withhold Medical
Care From a Bigot?
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(Include a daytime
phone number.)Shelbie writes:
I bring this dispute
against my husband,
Tyler. I plan to have
my car vacuumed
and cleaned before
trading it in. Tyler
says I’m wasting
my time — it’s
the dealership’s
job to clean it.
I disagree. Nobody
likes an icky car!
————
This is the second
letter I’ve received on
this subject. At first,
I thought the other
was Tyler with his
side of the story. But
no. Different couple.
So instead I have two
distinct data points
forming a trend:
Hetero married guys
hate the idea of
their wives cleaning
stuff for strangers. A
waste! they cry, and
fair point: Courtesy
isn’t precisely
efficient — especially
now, when only
monstrosity seems to
be rewarded. But this
feels like a cover for
their own slobbiness
and/or hatred of
car dealerships (fair)
and/or contempt
of any kindness not
focused on them. I
dunno. Ask Tyler. But
go ahead and wash
his neurosis right
out of your car, and
send it on its way!Bonus Advice
Fr o m J u d g e
John HodgmanThe Ethicist By Kwame Anthony Appiah