Ethical Considerations When Confronted by Racist Patients

A Black psychiatrist working on a general psychiatric unit wonders whether it is unethical to refuse to treat a patient who regularly refers to him using the N-word. The patient also refers to Black nurses and mental health aides in an analogous manner, creating a tense atmosphere on the unit.

The Black staff members describe the situation as daily emotional abuse, and some have called it a hate crime. Even the psychiatrist is struggling but puts up a brave face while on the unit. He believes he has an ethical obligation to continue to treat the patient, who also suffers from a psychotic disorder, but recognizes he is overwhelmed and exhausted by the effort.

Debates have arisen on the unit regarding how to proceed. On the one hand are those who believe the patient’s psychotic illness is responsible for his racist comments, implying that the comments should be ignored as the team focuses on treatment. On the other hand are those who insist racist behavior is always behavioral and not psychotic; after all, they argue, the patient had enough clarity of mind to correctly identify an individual’s race. They also maintain that the behavior serves a purpose for the patient beyond his illness. In addition, they worry about the effect of the racial slurs on other patients, especially Black patients, some of whom have threatened to assault the offender.

Abuse of psychiatrists, mostly verbal but sometimes physical, is common in psychiatric treatment, especially on inpatient units. For psychiatrists trained decades ago, experiencing verbal abuse and name calling from patients—and even senior colleagues and teachers—was the norm. The abuse began in medical school, with unconscionable work hours followed by callous disregard of students’ concerns and disparaging statements suggesting the students were too weak or unfit to be doctors.

This abuse continued into specialty training and practice. It was largely seen as a necessary evil of attaining the privilege of becoming a doctor and treating patients whose uncivil behaviors can be excused on account of their ill health. Doctors were supposed to rise above those indignities, focus on the task at hand, and get the patients better in line with our core ethical principles that place caring for the patient above all else. There was no room for discussion or acknowledgement of the doctors’ underlying life experiences, including past trauma, and how patients’ behavior would affect doctors.

Moreover, even in recent times, racial slurs or attacks against physicians of color were not recognized as abuse by the dominant group of doctors; the affected physicians who complained were dismissed as being too sensitive or worse. Some physicians, often not of color, have explained a manic patient’s racist comments as understandable in the context of disinhibition and poor judgment, which are cardinal symptoms of mania, and they are surprised that physicians of color are not so understanding.

Thankfully, there has been an increasing focus on physician wellness in recent years, an understanding that it is in the best interest of patients for physicians to be psychologically, emotionally, and physically stable. This has occurred in parallel with increased discussions on racial discrimination, equity, and justice, which have shone a spotlight on these issues.

Today, we know that a patient’s use of racial slurs against a psychiatrist of color elicits a trauma response compounded by generational and historical trauma. To ignore such reality and ask targeted psychiatrists to continue to treat the patient may not be in the best interest of the psychiatrist or the patient.

This problem calls for hospital leadership and management to develop a comprehensive plan on how to address racially charged situations. To start, a facility’s statement regarding its no-tolerance policy of abuse or violence should specifically include racist comments and behavior. Additionally, the plan should build in support for psychiatrists and other unit staff of color as well as milieu management to attend to the needs of other patients.

All staff members should deliver a uniform response to offending patients, denouncing the use of racial epithets. For the offending patients, a behavioral plan aimed at eliminating the behavior should be instituted as soon as possible and closely monitored.

And what about the psychiatrist at the beginning of this article? He should take an ethics timeout to carefully reflect on whether he can treat the patient fairly and without bias. Would his reactions to the patient’s racial abuse cause him to provide suboptimal (or even punitive) care consciously or unconsciously? He should also consider getting the opinion of a supportive colleague with whom he should discuss his reflections. If the psychiatrist believes or worries that he is not able to provide optimal care, he should transfer the patient to a colleague if resources so permit. ■

Charles C. Dike, M.D., M.P.H., is chair of the APA Ethics Committee and former chair of the Ethics Committee of the American Academy of Psychiatry and the Law. He is also a professor of psychiatry; co-director of the Law and Psychiatry Division at the Yale University School of Medicine; and medical director in the Office of the Commissioner, Connecticut Department of Mental Health and Addiction Services.