Past DMEJ Issues
DMEJ
Duke Medical Ethics Journal
Gender Preferences in Physician Choice:
An Epistemological Approach
By: Foxx Hart
Much has been written about gender bias in physician choice [1]. However, much of this literature focuses on how such biases effect the physician-patient encounter and under what circumstances such biases emerge [2]. There has been comparatively little written on the ethical impacts of accommodating such choices beyond applied case studies or legal disputes [3]. Thus, I seek to address the broader ethical implications of allowing gender bias in physician choice.
I want to focus specifically on hospitals’ decision(s) to accommodate gender bias in physician choice. I will not address whether such bias should effect hospital choice in general or how individuals choose their private providers. Instead, I will imagine a situation in which the patient has chosen to receive care from a hospital, either out of necessity or simple choice, and would now like their preferences to be accommodated.
A 2008 article in the American Medical Association Journal of Ethics argues for a utilitarian approach to gender preferences [4]. The authors argue that gender preferences should be adjudicated on a case-by-case basis, and should only be accommodated when doing so would not endanger the patient or others. This includes those who might be endangered in the future, say, if accommodating a preference caused a resident to lose a learning opportunity that may have consequences later. A 2019 New York Times article advocates a similar approach, and suggests trying to discern whether the motives for physician preference are legitimate or discriminatory [5]. An example of a legitimate preference the author cites is a woman who has been the victim of sexual assault asking for a female gynecologist. An example of a discriminatory preference the author gives is a real incident that occurred in Flint, Michigan, involving a man’s request that no Black nurses be involved in caring for his newborn child. The author argues that because this second request is disrespectful towards Black nurses, it should not be accommodated, and is meaningfully different from the earlier example of a woman who is the victim of sexual assault requesting a female doctor. The woman’s request is not the result of disrespect towards male physicians, the author argues, and therefore should be accommodated.
"The woman’s request is not the result of disrespect towards male physicians, the author argues, and therefore should be accommodated."
While common sense at first glance, I argue this case-by-case approach has many issues. First, allowing individual physicians and hospitals broad discretion in how they accommodate preferences creates inequities in physician training. Let’s imagine two hospitals, equally well- suited for teaching. The first hospital accommodates physician preferences; the second does not. Now let’s imagine two female physicians, equally capable, who begin training at these two different hospitals. As a result of accommodating physician preferences, the training received by the woman at the first hospital will necessarily be different than the woman receiving training at the second.
Let’s imagine that a once-in-a-career case comes to both emergency rooms. It’s a rare surgery that one must assist in to be able to perform it later on. The patient has a preference that only male doctors be allowed to assist on the surgery. The first hospital accommodates this preference. Despite being well-trained on all aspects of medicine necessary to become a practicing physician, the first female resident does not scrub in on this surgery. She becomes successful, but when the same once-in-a-career surgery comes to her later on, she fails to perform it correctly despite being well-trained, and the patient dies.
If this process is repeated on a large scale, the result is a continued mistrust of female physicians when performing this specific procedure. In comparison, the second hospital does not accommodate the patient’s preference, and the female resident is allowed to assist on the surgery. This gives her the necessary experience to perform the surgery later in her career, and when it comes along again, her patient lives. The second hospital’s policy thus works to erode the irrational bias against female physicians performing the procedure.
This is a simple example, but its implications are widespread. Maybe the first physician does get to perform the surgery, but she doesn’t get as much practice with it as the second. We can imagine sex-specific, “sensitive” medical procedures (those related to genital or sexual health) that might result in these skewed trainings [6]. For instance, one study found statistically significant evidence that patients who prefer a male physician for these procedures are more likely to be male [7]. Female residents must perform these procedures on male patients as part of their training, but if physician preferences are accommodated, they will necessarily be less skilled at it. The result of accommodating preferences is the cleaving of the medical field in two, where some procedures are only performed well by male physicians and some are only performed well by female physicians. If hospitals attempt to self-correct against these trends, the result only becomes messier. Some hospitals may overcorrect, and force female providers to conduct more “sensitive” procedures on male patients than they need to, while others may not correct enough. The result is simply that accommodating physician preferences creates unknowable inequities in physician training. We can estimate and attempt to correct for these inequities after they have been produced and solidified, but it is perhaps more productive to avoid them entirely by not accommodating physician preferences in the first place. There will inevitably be differences in physician training between different hospitals in any real-world scenario. However, refusing to accommodate physician preferences ensures these differences are not the result of an arbitrary and self-perpetuating bias.
The case-by-case approach to physician preference has another epistemological problem: it is impossible to know which preferences are legitimate and which are discriminatory. If a male patient’s initial physician is female, and they would prefer a male physician because they believe male physicians are better, they could ask for a male physician by claiming they are more comfortable being examined by someone of the same sex. This request is superficially to make a patient more comfortable, but is actually rooted in an irrational bias against female physicians. The hospital may grant this request, thus institutionalizing bias against female physicians, as was done against Black nurses in the Flint case [8].
Even if this hospital is complicit in its bias unknowingly, it does not change the fact that bias is being instituted. It is impossible to know the motivations for patients’ requests, and thus it is impossible for hospitals to be meaningfully sure they are not institutionalizing bias. Because hospitals cannot be sure of this, the safest option is to not accommodate physician preferences. This is the only scenario in which it can be known that a hospital’s policies on patient preferences are not producing institutionalized discrimination against certain demographics of physicians.
References
1. Haley A. Nolen et al, “Patient Preference for Physician Gender in the Emergency Department,” Yale Journal of Biology and Medicine 89, no. 2 (2016): 131-2, https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4918861/.
2. Nolen et al, 131-2.
3. Kimani Paul-Emile, “Patients' Racial Preferences and the Medical Culture of Accommodation,” PDF file, UCLA Law Review 60, no. 2 (2012): 462, https:// www.uclalawreview.org/pdf/60-2-3.pdf.
4. Muhammad Waseem and Aaron J. Miller, “Virtual Mentor,” American Medical Association Journal of Ethics 10, no. 7 (2008): 429-33, https://journalofethics.ama-assn.org/article/patient- requests-male-or-female-physician/2008-07.
5. Kwame A. Appiah, “Should Patients Be Allowed to Choose — or Refuse — Doctors by Race or Gender?” New York Times Magazine, Aug. 6, 2019, https://www.nytimes.com/2019/08/06/ magazine/should-patients-be-allowed-to-choose-or-refuse-doctors-by-race-or-gender.html.
6. Nolen et al, 133.
7. Nolen et al, 135.
8. Appiah, “Should Patients Be Allowed to Choose — or Refuse — Doctors by Race or Gender?”; Robin Erb, “Nurse sues after hospital grants dad's racial request,” Detroit Free Press (Detroit, MI), Feb. 18, 2013, https://www.usatoday.com/story/news/nation/2013/02/18/ black-nurse-lawsuit-father-request-granted/1928253/.