Can I Withhold Medical Care From a Bigot?

A patient started using slurs.

I am a physician, and last year, I took care of a white female patient in the hospital for a bacterial bloodstream infection. A few days into her stay, she began referring to Black staff members by the N-word and to our receptionist by an anti-gay slur. As the supervising physician, I made it clear that this was unacceptable. In general, with challenging patient behavior, I find it best to clearly lay out expectations and the consequences for violating them. So before talking to her, I discussed the situation with the nursing staff and hospital risk management, and we concluded that if she persisted in using this language, we would discharge her from the hospital, against her will if necessary.

I made all this clear to the patient. Thankfully, she stopped and completed the rest of her hospital treatment. But if she had continued using racist and homophobic slurs, would I have been wrong to force her to leave the hospital? Although she was medically stable, and we would have sent her home with oral antibiotics, a discharge would have been substandard care: Had she been discharged and not sought care with IV antibiotics elsewhere, there is a very real possibility that she could have died from her infection.

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Is hate speech grounds for refusing medically necessary care? I was taught in medical school that physical violence against staff, or the credible threat of violence, is grounds for refusing care, whereas rude, insulting or mean behavior from a patient is not. Hate speech seems to me to fall between these two categories.

Several Black nursing staff members felt strongly that this is what we needed to do, and I felt it was important to unequivocally support them. (I am a Hispanic, cisgender male.) But the patient had a substance-use disorder. This does not excuse her behavior, but it does put her in a more vulnerable category of patients. My assessment was that she was competent to make medical decisions, but I worry that her disease might have interfered with her ability to fully appreciate the consequences of her actions.

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