Second Opinion: The problem of racist patients
A recent issue of the British Medical Journal presents a debate on the question of 'dealing with racist patients' under the heading 'Ethical dilemma' (24 April). The discussion opens with an anecdote by a GP about her experience 10 years ago as a junior hospital doctor, when a patient expressed racist views which upset other patients and members of staff. At the time she ignored his 'appallingly racist' views and turned a blind eye when the ward sister created a 'Caucasian corner' to isolate him from ethnic minority patients. She now wonders whether she should have abandoned her cool 'courtesy' and responded more forcefully to his views.
A number of distinguished authorities then discuss the dilemma - ignore or confront a racist patient? Julia Neuberger, liberal rabbi and recently appointed chief executive of the King's Fund, a leading health think-tank, thinks doctors - and hospital managers - should give such a racist a good telling off.
Pippa Gough, director of policy at the Royal College of Nursing, asks, 'is it too extreme to suggest that one way forward might be to withdraw care until the patient changes his (or her) behaviour?', implying that it is not. She notes that this is what nurses do when physically threatened, for example by drunks in casualty. 'Why should racial abuse, which is assault by any definition, be different?'
I think most people would make a distinction between assault (physical attack causing injury) and abuse (verbal insult perhaps causing distress). While nobody could be expected to provide care for somebody who was physically attacking them, they might choose to ignore offensive attitudes expressed by somebody who was ill (the patient in question had had a small stroke and may have been confused).
It is striking that Ms Gough systematically inflates the offence caused by this racist, describing the pragmatic measures taken to isolate him as 'mini-apartheid' and characterising his obnoxious views as a form of racial violence. A pathetic, possibly demented, old man is depicted as a monster combination of PW Botha and Adolf Hitler. Just in case anybody missed her heavy-handed historical parallels, she concludes by warning that to fail to take action against such a man would be 'too close to the unjustifiable notion of "only following orders"'.
Ms Gough recognises that tough measures against patients with racist views 'might infringe on the individual's autonomy and right to freedom of speech and action'. Nevertheless, she thinks that such a policy should be drawn up, 'setting out the action to be taken in the situation described' and that this should be 'clearly displayed and publicised'.
The anti-racist zealotry currently prevailing in the medical establishment reflects a remarkable turnabout in attitudes. When I was a medical student and junior hospital doctor some 20 years ago, the problem I recall was that of dealing with racist doctors rather than racist patients.
I remember one consultant surgeon, who appeared to be prejudiced against every ethnic minority, and perhaps most of all, against the working class. As we scrubbed up in the operating theatre, he would ventilate these prejudices with his registrar, who appeared to share them fully, and has since himself become a consultant in an area with a high ethnic minority population.
My dilemma was whether to ignore this racist banter or spoil the fun by interjecting a dissenting view. In fact, having tried both tactics on different occasions with indifferent success, I developed another approach. Instead of standing aloof or being critical, I would join in and agree, for example, that 'muggings' by black youth were a major social problem. I would then suggest ever-more extreme solutions to this problem, forcing them to outbid me, until we reached summary execution and they started backing off uneasily from the consequences of their arguments.
In the not-so-distant past, the medical profession shared the assumption of racial superiority that was common to the elite of one of the world's leading imperial powers. The canteen culture of medical students and junior hospital doctors reflected this discreet but pervasive climate of racial prejudice. Now that the principles of anti-racism are proclaimed by everybody from the prime minister to the chief constable of the Metropolitan Police, doctors too have come out against racial prejudice.
The first time I recall doctors denouncing racism among their patients was in response to the election of a councillor from the British National Party in the Isle of Dogs in September 1993. Radical GPs in east London circulated a 'statement against racism' which condemned the election (implicitly the voters) and warned that racist abuse from patients would 'lead to removal from the building and the practice list'.
The irony of this statement was that it followed a tradition of racial discrimination within general practice itself in east London. Until 10 years ago there were very few reception staff from ethnic minorities and I can recall numerous incidents of staff both expressing racist views and treating ethnic minority patients badly. In some practices in the 1980s staff went out of their way to assist the immigration authorities by demanding to see passports and other forms of identification before agreeing to register patients.
Yet now that doctors have become staunch anti-racists, they proclaim 'zero tolerance' for views which many only recently shared or condoned. Furthermore, such is the moral fervour of their newfound commitment that they are ready to exclude from medical treatment patients whose attitudes lag behind the new consensus.
Though it is no longer acceptable in medical circles to express prejudices against black people (or women or gays), if you raise the issues of asylum seekers, refugees or travellers, you may find that the old prejudices have not gone away, but have simply found a new target. And as for those people on council estates...
Dr Michael Fitzpatrick
Reproduced from LM issue 121, June 1999