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Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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41. Racial Concordance
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Congratulate the medical practitioner on their choice of calling, which offers a combination of intellectual and moral interests found in no other profession.
~ Sir William Osler
Concordance Conundrum
Racial Concordance and the Ethics of Patient Autonomy in Medicine
It was a typical Wednesday afternoon at Mercy Hospital when a patient, Mrs. Smith, was rushed into the emergency room with a severe case of pneumonia. As Mrs. Smith was being assessed by the medical team, it became clear that she needed to be admitted to the hospital. Dr. Johnson, the attending physician, was informed and immediately began to review her chart. As he looked at the chart, he realized that the patient had requested a racially concordant physician. This was a problem because Dr. Johnson was a Caucasian male, and Mrs. Smith had requested a physician who shared her African American phenotype and cultural identity.
Dr. Johnson, feeling uneasy about this situation, decided to call his colleague, Dr. Jones, who was an African American physician. Dr. Jones agreed to take on Mrs. Smith’s case and immediately went to the hospital to meet with her. As Dr. Jones spoke with Mrs. Smith, he noticed that she was apprehensive and somewhat guarded. However, as he began to talk about her medical condition and explain her treatment options, Mrs. Smith seemed to relax and become more engaged in the conversation.
Dr. Johnson was pleased with the outcome of the situation and felt that Dr. Jones had handled the case well. However, as he reflected on the incident, he realized that there was a much more significant issue at play. The patient’s preference for a racially concordant physician raised concerns about discrimination, bias, and healthcare disparities.
Dr. Johnson decided to organize a meeting with the hospital’s medical staff to discuss the importance of racial concordance in medicine and the ethical implications of patients’ autonomy in choosing their physicians. He emphasized that while patients have the right to choose their physicians based on their personal preferences, practitioners must ensure that they do not discriminate or violate any anti-discriminatory laws.
The meeting was productive, and the medical staff agreed to take a more proactive approach to addressing healthcare disparities and reducing biases. Dr. Johnson was pleased with the outcome of the meeting and felt that it was a step in the right direction.
However, the next day, Dr. Johnson was shocked to hear that Dr. Jones had been found dead in his office. The police were called in to investigate, and it was quickly determined that Dr. Jones had been murdered.
The investigation revealed that Dr. Jones had been receiving threatening messages from an anonymous source who was angry about his willingness to treat patients of all races and ethnicities. The culprit was eventually caught and brought to justice, but the incident left a lasting impact on the hospital and the medical community.
Dr. Johnson knew that the murder of his colleague was a tragic reminder of the importance of addressing healthcare disparities, reducing biases, and ensuring that patients receive the best possible care, regardless of their race or ethnicity. He made a commitment to continue to educate himself and his colleagues on the topic of racial concordance and to work towards creating a more inclusive and equitable healthcare system for all.
Abstract
Racial concordance in medicine, refers to the idea that patients prefer to choose a practitioner who shares the same phenotype and cultural identity. As society becomes more diverse, it is argued that the medical workforce should also reflect this diversity. The patient-practitioner relationship is considered crucial in medical care, and racial concordance is believed to help enhance this relationship. Patients have the autonomy to choose practitioners who they feel most comfortable with, while practitioners have the obligation to maximize patient interests and reduce healthcare disparities. The medical profession must recognize that unjust discrimination is illegal, unprofessional, and unethical, and practitioners must be self-reflective to recognize implicit biases and follow medical standards of care. The professional character of practitioners is crucial for providing society with stability and consistency in medical care.
**
Think
[41:1] Race is a social construct based on phenotype, meaning observable characteristics or traits of an organism. Racial concordance in medicine occurs when the practitioner and patient have the same phenotype and cultural identity. Research has shown that racial concordance is what patients want to choose, autonomy (informed consent), and what patients are most comfortable with.
[41:2] As communities get more racially diverse, racial concordance argues that so should the medical workforce, so that patients can select practitioners who share the same phenotype and cultural identity if they so desire. The patient-practitioner relationship is the cornerstone of medical care, and it is said that racial concordance helps to promote, augment, and strengthen that personalized relationship.
Assess
Patient: 1) Autonomy
[41:3] Patients are vulnerable, and as vulnerable individuals, it is understandable that patients will autonomously choose to have a patient-practitioner relationship with those most similar to themself. These autonomous preferences are based on the essential elements of the patient-practitioner relationship of mutual trust, effective communication, and empathy which the patient believes is greater with a practitioner who has a similar phenotype and culture.
[41:4] Society and the medical profession recognize that patients have the constitutional right of freedom of association to make individualized judgments of whom they wish to establish the patient-practitioner relationship, even though evidence-based medicine, in and of itself, is independent of phenotype and culture.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[41:5] Those individual rights and liberties that patients have in selecting their practitioner are not reciprocal. Practitioners, as a profession, do not have the right or liberty to select patients based on phenotype or culture.
[41:6] The prime directive of the medical professional is to maximize the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities using the moral principles of beneficence (do good) and nonmaleficence (do no harm).
[41:7] Most of the time, the patient’s reasonable goals, values, and priorities converge on the same end, no matter the patient’s phenotype or culture. This shared end is the patient’s health and recovery from illness. Treatment for this end is also independent of phenotype and culture as it is determined by evidence-based medicine using medical standards of care. Evidence-based medicine should be independent of phenotype and culture.
[41:8] The American Medical Association (AMA) 1.1.2 Prospective patients states:
Physicians [practitioners] must also uphold ethical responsibilities not to discriminate against a prospective patient based on race, gender, sexual orientation or gender identity, or other personal or social characteristics that are not clinically relevant to the individual’s care.
[41:9] As a medical professional, the practitioner is obligated to help reduce healthcare disparities by treating all patients who require their services regardless of their personal or social characteristics that are independent of evidence-based medicine and medical standards of care.
Public Policy: 4) Justice
[41:10] Discriminations that result in the violation of fundamental rights and liberties are, by definition, socially unjust (not fair). Title VII of the Civil Rights Act of 1964 (Title VII) and other federal laws prohibit discrimination based on national origin, race, color, religion, sex, age, disability, and genetic information.
[41:11] Healthcare disparities are just one of many negative consequences that have come about because of conscious and unconscious biases and violations of anti-discriminatory laws.
Conclude
[41:12] The medical practitioner must recognize that treating patients equally and not violating fundamental rights and liberties is always a given and unjust discrimination is illegal, unprofessional, and unethical. Practitioners must be self-reflective and able to recognize the existence of implicit or unconscious biases and, as a result, follow medical standards of care which mitigate those biases. The practitioner’s professional character provides society with the stability and consistency that they expect from medical practitioners.
[41:12] In summary, racial concordance in medicine refers to the patient’s preference for a practitioner who shares the same phenotype and cultural identity. Patients have the autonomy to choose practitioners they feel most comfortable with, while practitioners have the obligation to maximize patient interests and reduce healthcare disparities. Discrimination is illegal, unprofessional, and unethical. Practitioners must recognize implicit biases and follow medical standards of care. The professional character of practitioners is crucial for providing society with stability and consistency in medical care.
(See 53. Structural Injustice)
**
41. Review Questions
1. Race is a social construct based on phenotype, meaning observable characteristics or traits of an organism.
2. Racial concordance in medicine occurs when the practitioner and patient have the same phenotype and cultural identity.
3. As communities get more racially diverse, racial concordance argues that so should the medical workforce so that patients can select practitioners who share the same phenotype and cultural identity if they so desire.
4. Society and the medical profession recognize that patients have the constitutional right of freedom of association to make individualized judgments of whom they wish to establish the patient-practitioner relationship, even though evidence-based medicine, in and of itself, is independent of phenotype and culture.
5. Individual rights and liberties that patients have in selecting their practitioner are reciprocal. Practitioners, as a profession, have the same rights and liberties as patients to select patients based on phenotype or culture.
6. The prime directive of the medical professional is to maximize the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities using the moral principles of beneficence (do good) and nonmaleficence (do no harm).
7. Most of the time, the patient’s reasonable goals, values, and priorities will be different from that of the practitioner’s, which is why phenotype or cultures are so important for determining what end the patients want.
8. Title VII and other federal laws prohibit discrimination based on national origin, race, color, religion, sex, age, disability, and genetic information.
**
CORRECT! 🙂
[41:1] Race is a social construct based on phenotype, meaning observable characteristics or traits of an organism. Racial concordance in medicine occurs when the practitioner and patient have the same phenotype and cultural identity. Research has shown that racial concordance is what patients want to choose, autonomy (informed consent), and what patients are most comfortable with.
Wrong 😕
[41:1] Race is a social construct based on phenotype, meaning observable characteristics or traits of an organism. Racial concordance in medicine occurs when the practitioner and patient have the same phenotype and cultural identity. Research has shown that racial concordance is what patients want to choose, autonomy (informed consent), and what patients are most comfortable with.
CORRECT! 🙂
[41:1] Race is a social construct based on phenotype, meaning observable characteristics or traits of an organism. Racial concordance in medicine occurs when the practitioner and patient have the same phenotype and cultural identity. Research has shown that racial concordance is what patients want to choose, autonomy (informed consent), and what patients are most comfortable with.
Wrong 😕
[41:1] Race is a social construct based on phenotype, meaning observable characteristics or traits of an organism. Racial concordance in medicine occurs when the practitioner and patient have the same phenotype and cultural identity. Research has shown that racial concordance is what patients want to choose, autonomy (informed consent), and what patients are most comfortable with.
Wrong 😕
[41:2] As communities get more racially diverse, racial concordance argues that so should the medical workforce so that patients can select practitioners who share the same phenotype and cultural identity if they so desire. The patient-practitioner relationship is the cornerstone of medical care, and it is said that racial concordance helps to promote, augment, and strengthen that personalized relationship.
CORRECT! 🙂
[41:2] As communities get more racially diverse, racial concordance argues that so should the medical workforce so that patients can select practitioners who share the same phenotype and cultural identity if they so desire. The patient-practitioner relationship is the cornerstone of medical care, and it is said that racial concordance helps to promote, augment, and strengthen that personalized relationship.
CORRECT! 🙂
[41:4] Society and the medical profession recognize that patients have the constitutional right of freedom of association to make individualized judgments of whom they wish to establish the patient-practitioner relationship, even though evidence-based medicine, in and of itself, is independent of phenotype and culture.
Wrong 😕
[41:4] Society and the medical profession recognize that patients have the constitutional right of freedom of association to make individualized judgments of whom they wish to establish the patient-practitioner relationship, even though evidence-based medicine, in and of itself, is independent of phenotype and culture.
Wrong 😕
[41:5] Those individual rights and liberties that patients have in selecting their practitioner are not reciprocal. Practitioners, as a profession, do not have the right or liberty to select patients based on phenotype or culture.
CORRECT! 🙂
[41:5] Those individual rights and liberties that patients have in selecting their practitioner are not reciprocal. Practitioners, as a profession, do not have the right or liberty to select patients based on phenotype or culture.
CORRECT! 🙂
[41:6] The prime directive of the medical professional is to maximize the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities using the moral principles of beneficence (do good) and nonmaleficence (do no harm).
Wrong 😕
[41:6] The prime directive of the medical professional is to maximize the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities using the moral principles of beneficence (do good) and nonmaleficence (do no harm).
Wrong 😕
[41:7] Most of the time, the patient’s reasonable goals, values, and priorities converge on the same end, no matter the patient’s phenotype or culture. This shared end is the patient’s health and recovery from illness. Treatment for this end is also independent of phenotype and culture as it is determined by evidence-based medicine using medical standards of care. Evidence-based medicine should be independent of phenotype and culture.
CORRECT! 🙂
[41:7] Most of the time, the patient’s reasonable goals, values, and priorities converge on the same end, no matter the patient’s phenotype or culture. This shared end is the patient’s health and recovery from illness. Treatment for this end is also independent of phenotype and culture as it is determined by evidence-based medicine using medical standards of care. Evidence-based medicine should be independent of phenotype and culture.
CORRECT! 🙂
[41:10] Discriminations that result in the violation of fundamental rights and liberties are, by definition, socially unjust (not fair). Title VII of the Civil Rights Act of 1964 (Title VII) and other federal laws prohibit discrimination based on national origin, race, color, religion, sex, age, disability, and genetic information.
Wrong 😕
[41:10] Discriminations that result in the violation of fundamental rights and liberties are, by definition, socially unjust (not fair). Title VII of the Civil Rights Act of 1964 (Title VII) and other federal laws prohibit discrimination based on national origin, race, color, religion, sex, age, disability, and genetic information.
41. Clinical Vignettes
1. Mr. Johnson, a 45-year-old African American man, presents to his primary care practitioner with complaints of shortness of breath, chest pain, and fatigue. He reports a history of hypertension and smoking. The practitioner, Dr. Andrew Lee, is a 35-year-old Asian American woman. Mr. Johnson expresses a preference to see a practitioner of the same race as he feels more comfortable with someone who understands his culture and experiences. Dr. Lee believes that race and culture are not relevant to providing evidence-based medical care and that she can provide the best medical care for Mr. Johnson.
2. Ms. Garcia is a 35-year-old Hispanic woman who presents with symptoms of anxiety and depression. She is a stay-at-home mother who is struggling to manage her daily tasks due to her mental health concerns. Her differential diagnosis includes generalized anxiety disorder, major depressive disorder, and adjustment disorder with mixed anxiety and depressed mood. Should a healthcare practitioner of a different race and culture than the patient prioritize the patient's request for a practitioner of their own race and culture, even if it means the patient has to wait longer for care?
3. Ms. Nolan is a 45-year-old African American woman who presents to her primary care practitioner with complaints of fatigue, shortness of breath, and chest pain. She has a history of hypertension and hyperlipidemia, and works as a teacher at a predominantly African American school. Her practitioner, Dr. Lee, is a Korean American woman who has been practicing for 10 years. During the visit, Ms. Nolan expresses a preference to see a practitioner who shares her racial and cultural background. Which of the following best represents Dr. Lee's ethical obligation in this situation?
4. Ms. Isabel Cruz is a 55-year-old white woman who has been experiencing abdominal pain for the past few weeks. She visits her primary care practitioner, Dr. Jackson, and requests to see a white practitioner as she feels more comfortable with someone of her own race. Dr. Jackson is conflicted as she believes in providing equitable care to all patients, regardless of their race.
5. Ms. Alice Gray is a 45-year-old white woman who presents to the clinic with a persistent cough, fever, and shortness of breath. She has a history of smoking and works as a receptionist in a dental office. The differential diagnosis includes pneumonia, bronchitis, and COVID-19. The practitioner is hesitant to mention her race and cultural identity during the consultation, as she is concerned that racial concordance may lead to discriminatory behavior, and that the patient may refuse treatment or become distrustful if the practitioner does not share the same phenotype.
CORRECT! 🙂
Explanation: Dr. Lee should engage in a conversation with Mr. Johnson to understand his concerns and try to provide reassurance that she is competent and caring. Racial concordance is a valid preference that patients have the autonomy to choose, and practitioners must respect these preferences as part of patient-centered care [41:3]. The patient-practitioner relationship is built on mutual trust, effective communication, and empathy, which may be strengthened through racial concordance [41:4]. However, practitioners have the obligation to maximize patient interests using the moral principles of beneficence and nonmaleficence and not discriminate based on race, gender, or other personal characteristics [41:5-6, 41:8]. Dr. Lee should not transfer Mr. Johnson's care solely based on his race, but should address his concerns and communicate that she is capable and committed to providing the best care possible for him.
Wrong 😕
Explanation: Dr. Lee should engage in a conversation with Mr. Johnson to understand his concerns and try to provide reassurance that she is competent and caring. Racial concordance is a valid preference that patients have the autonomy to choose, and practitioners must respect these preferences as part of patient-centered care [41:3]. The patient-practitioner relationship is built on mutual trust, effective communication, and empathy, which may be strengthened through racial concordance [41:4]. However, practitioners have the obligation to maximize patient interests using the moral principles of beneficence and nonmaleficence and not discriminate based on race, gender, or other personal characteristics [41:5-6, 41:8]. Dr. Lee should not transfer Mr. Johnson's care solely based on his race, but should address his concerns and communicate that she is capable and committed to providing the best care possible for him.
CORRECT! 🙂
Explanation: The medical profession must recognize that unjust discrimination is illegal, unprofessional, and unethical [41:1]. Patients have the autonomy to choose practitioners who they feel most comfortable with, but practitioners, as a profession, do not have the right or liberty to select patients based on phenotype or culture [41:5]. The prime directive of the practitioner is to maximize the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities using the moral principles of beneficence and nonmaleficence [41:6]. Therefore, the practitioner should not prioritize the patient's request based on race and culture as it could perpetuate racial discrimination and result in unequal access to healthcare [41:9, 41:11]. Instead, the practitioner should focus on providing evidence-based, culturally sensitive care and fostering a positive patient-practitioner relationship through effective communication and empathy.
Wrong 😕
Explanation: The medical profession must recognize that unjust discrimination is illegal, unprofessional, and unethical [41:1]. Patients have the autonomy to choose practitioners who they feel most comfortable with, but practitioners, as a profession, do not have the right or liberty to select patients based on phenotype or culture [41:5]. The prime directive of the practitioner is to maximize the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities using the moral principles of beneficence and nonmaleficence [41:6]. Therefore, the practitioner should not prioritize the patient's request based on race and culture as it could perpetuate racial discrimination and result in unequal access to healthcare [41:9, 41:11]. Instead, the practitioner should focus on providing evidence-based, culturally sensitive care and fostering a positive patient-practitioner relationship through effective communication and empathy.
CORRECT! 🙂
Explanation: Dr. Lee's ethical obligation is to maximize Ms. Nolan's best interests while minimizing healthcare disparities [41:6]. While patients have the autonomy to choose practitioners who they feel most comfortable with [41:3], practitioners do not have the right to select patients based on phenotype or culture [41:5]. Dr. Lee must recognize and address any implicit biases that may impact her decision-making, and discuss the benefits and limitations of racial concordance with Ms. Nolan [41:2]. Through effective communication and empathy, Dr. Lee can help establish a trusting and personalized patient-practitioner relationship [41:2][41:3], while still adhering to evidence-based medicine and medical standards of care [41:7]. Racial concordance in medicine is believed to help enhance the patient-practitioner relationship [41:2], but evidence-based medicine should be independent of phenotype and culture [41:7].
Wrong 😕
Explanation: Dr. Lee's ethical obligation is to maximize Ms. Nolan's best interests while minimizing healthcare disparities [41:6]. While patients have the autonomy to choose practitioners who they feel most comfortable with [41:3], practitioners do not have the right to select patients based on phenotype or culture [41:5]. Dr. Lee must recognize and address any implicit biases that may impact her decision-making, and discuss the benefits and limitations of racial concordance with Ms. Nolan [41:2]. Through effective communication and empathy, Dr. Lee can help establish a trusting and personalized patient-practitioner relationship [41:2][41:3], while still adhering to evidence-based medicine and medical standards of care [41:7]. Racial concordance in medicine is believed to help enhance the patient-practitioner relationship [41:2], but evidence-based medicine should be independent of phenotype and culture [41:7].
Wrong 😕
Explanation: Racial concordance can be seen as discriminatory as it perpetuates the idea that race is a determining factor in the patient-practitioner relationship [41:2]. It also goes against the ethical principles of nonmaleficence and justice [41:5] and violates anti-discriminatory laws [41:10]. Dr. Jackson should explain to Ms. Cruz that it is important to provide equitable care to all patients, regardless of their race, and that medical standards of care are evidence-based and should be independent of race [41:7]. By providing Ms. Cruz with education on the importance of equitable care and not honoring her request based on race, Dr. Jackson is upholding her ethical responsibilities as a medical professional [41:8].
CORRECT! 🙂
Explanation: Racial concordance can be seen as discriminatory as it perpetuates the idea that race is a determining factor in the patient-practitioner relationship [41:2]. It also goes against the ethical principles of nonmaleficence and justice [41:5] and violates anti-discriminatory laws [41:10]. Dr. Jackson should explain to Ms. Cruz that it is important to provide equitable care to all patients, regardless of their race, and that medical standards of care are evidence-based and should be independent of race [41:7]. By providing Ms. Cruz with education on the importance of equitable care and not honoring her request based on race, Dr. Jackson is upholding her ethical responsibilities as a medical professional [41:8].
Wrong 😕
Explanation: Racial concordance in medicine can lead to discriminatory behavior, and the practitioner's primary obligation is to ensure that the patient receives the best possible care [41:6]. The patient's autonomy to choose a practitioner based on race and cultural identity is recognized; however, the practitioner is obligated to follow medical standards of care, which are independent of phenotype and culture [41:4]. The American Medical Association (AMA) upholds the ethical responsibility of not discriminating against patients based on race or culture [41:8]. The practitioner should not disclose their race or cultural identity, as it may be perceived as discriminatory or unprofessional [41:5]. The practitioner should explain the ethical and professional responsibilities to Ms. Gray and assure her that the treatment will be evidence-based and independent of phenotype and culture [41:9].
CORRECT! 🙂
Explanation: Racial concordance in medicine can lead to discriminatory behavior, and the practitioner's primary obligation is to ensure that the patient receives the best possible care [41:6]. The patient's autonomy to choose a practitioner based on race and cultural identity is recognized; however, the practitioner is obligated to follow medical standards of care, which are independent of phenotype and culture [41:4]. The American Medical Association (AMA) upholds the ethical responsibility of not discriminating against patients based on race or culture [41:8]. The practitioner should not disclose their race or cultural identity, as it may be perceived as discriminatory or unprofessional [41:5]. The practitioner should explain the ethical and professional responsibilities to Ms. Gray and assure her that the treatment will be evidence-based and independent of phenotype and culture [41:9].
**
41. Reflection Vignettes
1. Dr. Maria Rodriguez is a 35-year-old medical practitioner with a specialization in family medicine. She opens her practice in a neighborhood with a large Latino population because she identifies as Latina and believes that having shared ethnicity and cultural background with her patients will result in better outcomes. She believes that her patients will feel more comfortable with her and trust her more readily. Additionally, she believes that having a deep understanding of her patients' cultural and linguistic nuances will allow her to provide more effective care. However, some critics argue that selecting patients based on ethnicity can be discriminatory and goes against the principles of medical ethics, which requires physicians to provide equal care to all patients.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
2. Dr. Emma Thompson is a 35-year-old physician who recently opened her own medical practice in a diverse urban community. As she begins to interview candidates for medical office staff and other interprofessional positions, Dr. Thompson notices that her patients seem to respond differently to staff members of different phenotypes and sexes. To ensure her patients are comfortable and well-served, Dr. Thompson decides to hire based on positive biases, selecting candidates whose phenotypes and sexes match those of her patients. While Dr. Thompson is confident that this hiring strategy is the best way to serve her patients, she begins to receive criticism from colleagues and community members who question the ethics of her approach.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
