Discrimination and Racial Hostility in the ICU

2017 - 4 August – Diversity
Michael D. Williams, MD, FACS; Mary Faith Marshall, PhD, FCCM
This article addresses the ethics of discrimination and racial hostility in the ICU.

CASE STUDY
A 76-year-old woman is admitted to the surgical intensive care unit (ICU) after surgery for a ruptured abdominal aortic aneurysm. She is in shock and on vasopressors for the first 24 hours of her stay. Over time she recovers and is successfully weaned from mechanical ventilation and extubated. At the time of her extubation, the nurse caring for her is a first-generation immigrant from sub-Saharan Africa. Among the first words that the patient speaks after her endotracheal tube is removed are: “I don’t want that ‘N-word’ anywhere near me.” When examined further, she is found to be alert and completely oriented. She simply has a strong bias against black people.

ANALYSIS
Background
“There’s something wrong when a person can go to work, be subject to intolerance or abuse, and have it be ignored and accepted by colleagues as part of the job.”

Racial discrimination at the bedside is not new. In a 2012 law review article, Paul-Emile Kimani noted: “When we think of race discrimination in healthcare today, we tend to think about race-based health disparities and bias exhibited by physicians or other providers, but new studies illuminate a different kind of race discrimination in the hospital setting. Today, rather than turning patients away based on race, healthcare providers are instead facilitating patients’ racial biases by enabling them to turn physicians  away based on race. In other words, healthcare providers accommodate patients’ racial preferences.”2

Accommodation of patients’ racial (or other demographic) requests for provider type has been shown to have positive health effects. But such accommodations also violate principles such as respect for persons and justice that underlie antidiscrimination and federal and state civil rights laws, and perpetuate intolerance and racial inequality. There have been several lawsuits by clinical staff against medical centers in cases of accommodation of racial requests​.

Our medical center has seen a recent and unfortunate trend among patients and visitors who seem emboldened by the current sociopolitical climate to freely exhibit their prejudices. Such behaviors at the bedside demonstrate a more widespread social phenomenon. The Ku Klux Klan has rallied several times in our community to protest the removal of a Confederate statue. Neighborhoods have been blanketed with flyers alleging genocidal campaigns to “erase white people from the face of the earth.” Gregory Townsend, MD, School of Medicine Associate Dean for Diversity, laments, “I have lived here for most of the last 35 years, going back to when I was a med student here. My wife found these in our driveway Monday—the first time​ that we have experienced anything like this. I’m assuming that we weren’t specifically targeted but were just part of a blanket ‘outreach’ in our (mostly white) neighborhood. What is going on?”

We are not alone in this upsurge of discrimination and hostility. A recent New England Journal of Medicine article addressed an increase in the United States of racial hostility and political polarization and, in particular, examined the role that the recent presidential election has played in surfacing preexisting racial and other discriminatory animus.More than half of the respondents to a survey of K-12 teachers revealed that “since the 2016 presidential campaign began, many of their students have been ‘emboldened’ to use slurs and name calling and to say bigoted and hostile things about minorities, immigrants, and Muslims.”4

Research shows adverse physical and mental health effects of racial discrimination on individuals and communities, including epigenetic patterns of aging, elevated risk of death, and adverse health effects not only through particular experiences of discrimination, but also through rumination, vigilance, and worry over potential exposures.3

Case Study Analysis
Patients are neither legally nor ethically entitled to the provision of care by a clinician of a certain demographic profile (e.g., age, race, gender, sexual orientation, or religious affiliation). Patients have the right to refuse treatment from a clinician who does not meet a certain demographic profile and are entitled to choose another venue for their healthcare. This is not so easily done when a patient is in extremis in the emergency department or the ICU.

Using a framework that includes assessing patient acuity (we would add decisional capacity), cultivating a therapeutic alliance, depersonalizing the event, and ensuring a safe learning environment, Whitgob et al have  developed response strategies for discrimination against trainees that include faculty and trainee development, frontline faculty interventions, and institutional preparedness and response.5

Our academic health center has implemented a comprehensive plan to address discrimination of any kind in the workplace. A multidisciplinary task force comprising students, faculty, staff, academic deans, and medical center administrators developed and implemented the following strategies with the goal of demonstrating our commitment to inclusion and diversity versus simply telling others about it.

  1. Policy: Our institutional Patient Rights and Responsibilities Policy states that patients are responsible for “show[ing] respect for all patients, visitors, and staff as well as following instructions, policies, rules, and regulations in place to support quality care for patients and a safe environment for all individuals in the hospital,” and for “follow[ing] the Medical Center rules and regulations concerning patient care and conduct while on Medical Center property, including refraining from: Engaging in verbal or physical abuse.”
  2. Messaging: Banners throughout the Medical Center and text in patient materials state, “Respect: We are committed to a culture that promotes equity, diversity, and inclusiveness.”
  3. Counseling: A confidential ombudsperson who exclusively addresses issues of discrimination is available for all Health Sciences Center employees, faculty and students.
  4. Education and Training: Educational, onboarding, and resource materials as well as plans for training staff, faculty, and students have been developed.
How to respond to the patient?
  1. Assess her decisional capacity and acuity.
  2. Counteract the “bystander effect,” in which discrimination or racial hostility occurs in view of witnesses who fail to intervene. Bystanders should intervene by speaking up and affirming the targeted person’s competence, skill, and value as a member of the healthcare team.
  3. Do not shame the patient, but explain that this is an nstitution of healing, respect, and inclusiveness.
  4. Immediately debrief with the targeted person and others.
  5. Refer the targeted person to the ombudsperson.
  6. Report the incident to administration.
Academic (and other) health centers are moral communities and parts of larger social communities. Our university president and vice-president for health affairs exemplified this with their reaction to the planned Ku Klux Klan rally: “Beliefs that endorse hatred, exclusion, and intolerance are not only condemned here, but they are in absolute contradiction to our values. Placing our patients’ needs first, caring for each other, and basing all of our actions on our ASPIRE [accountability, stewardship, professionalism, integrity, respect, excellence] values is the foundation of our roles as healers who promote the well-being of all in our community.” They arranged for counseling services during and after the rally, Health System Emergency Management collaboration with city safety partners, extra security at the Medical Center, and widely distributed information about planned alternative community events that celebrated respect for all. 

References
1. Jain SH. The racist patient. Ann Intern Med. 2013 Apr;158(8):632.
2. Kimani P-E. Patients’ racial preferences and the medical culture of accommodation. 60 UCLA L Rev. 462;2012.
3. Williams DR, Medlock MM. Health effects of dramatic societal events—ramifications of the recent presidential election. N Engl J Med. 2017 Jun 8;376(23):2295-2299.
4. Costello MB. The Trump Effect: The Impact of the Presidential Campaign on Our Nation’s Schools. Montgomery, AL: Southern Poverty Law Center;2016.
5. Whitgob EE, Blankenburg RL, Bogetz AL. The discriminatory patient and family: strategies to address discrimination towards trainees. Acad Med. 2016 Nov;91(11 Association of American Medical Colleges Learn Serve Lead: Proceedings of the 55th Annual Research in Medical Education Sessions):S64-S69.

Editor’s Note: This article was authored before the events that transpired in Charlottesville, Virginia, on August 11-12, 2017.​