Treating an Unfavorable Patient

The tragic and horrific school shooting in Parkland, Florida on February 14th was unique. The shooter survived -- and was treated in an emergency department after committing his heinous crimes. As a future clinician, I imagined myself in the position of the doctor(s) who treated him. They had to juggle so much: keeping composure, concern for personal safety, and managing the mountain of visceral, natural biases against the culprit, all while attempting to provide him with the same care provided to all other patients.

As aspiring providers, we will be put in situations where the patient may be far from ideal, whether it be a rude patient, a racist one, or possibly one that tries to dismantle the sanctity of our society. What is expected in these circumstances? The implications of the bioethical principle of justice means that we should strive to be fair and equal to all people [1]. But in these difficult circumstances, is it possible to abstain from making moral judgements on patients?

Based on research, it is extremely difficult to completely eliminate all biases, both implicit and explicit from daily life, let alone patient care. But this is not to say you must treat every unfavorable patient. An article published by NEJM provides a flow-chart to help assess whether it is appropriate for bigoted patients to be reassigned per their request [2]. In terms of the physician’s requests, ethically, it is clear that when biases and conflict interfere with providing neutral care to the patient, and the patient is stable, then it may be appropriate to defer care to another party. In the case of the shooter, EMTALA protects his care, ensuring public access to emergency services [3]. When the option of transfer is not available, particularly in emergent situations, the circumstances are tough. However, there are steps that can be taken to ensure that tough situations are handled in an ethical manner. An important step is acknowledging the bias. This is difficult. It requires honesty and practice. However, research by PEHM shows that “cognitive reappraisal is shown to have far healthier personal and interpersonal consequences than emotion suppression strategies [4].” It means that understanding the bias or negative reaction, but also shifting the focus to something else, like the professional commitment or the ethical standard that is required for a physician. This can help make an otherwise dreadful situation more bearable, mitigate the psychological impact on the provider, and promote ethical care.

[1] Thompson, I. E. (1987). Fundamental ethical principles in health care. British Medical Journal (Clinical Research Ed.), 295(6611), 1461–1465.

[2] Paul-Emile, K., Smith, A. K., Lo, B., & Fernández, A. (2016). Dealing with Racist Patients. New England Journal of Medicine, 374(8), 708-711. doi:10.1056/nejmp1514939

[3] Emergency Medical Treatment and Labor Act (EMTALA). CMS.gov (http://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html?redirect=/EMTALA).

[4] Hill, T. E. (2010). How clinicians make (or avoid) moral judgments of patients: implications of the evidence for relationships and research. Philosophy, Ethics, and Humanities in Medicine : PEHM, 5, 11. http://doi.org/10.1186/1747-5341-5-11