Return to APA Newsletters IndexThe following appeared in Volume 97, Number 2 (Spring, 1998) of the APA Newsletters
Quality Care and the Wounds of Diversity
Kenneth Kipnis, Ph.D.
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 he 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 unaccom-modatable 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, knowledge, 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.
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.
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