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Can I Withhold Medical Care From a Bigot?

The magazine’s Ethicist columnist on a physician’s duties.

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.

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. Name Withheld

The responsibilities of clinicians should be configured in the light of the long experience of their professions. But these are social roles, and — given that we can all end up as patients, and we all contribute to the provision of health care resources — society has a part to play in determining what they should be. What we’ve decided is that the norms governing medical care are to be primarily concerned with the welfare of the sick. The workplace environment should minimize avoidable injury and insult to health care providers, but not at the expense of that basic aim.

It was entirely proper to tell this patient to stop using racist or homophobic slurs — language that’s offensive whether or not it is addressed to those it derogates. And the Black members of your nursing staff justly value a workplace in which they are treated respectfully; that’s surely something every employee deserves. The question is what you should do when someone ignores this simple moral demand. And here your first consideration must be the risk to a patient of discharging her.

Clinicians have duties of care to patients, even odious ones.

This woman wasn’t in your hospital for some optional cosmetic procedure. She was being hospitalized for a possibly lethal condition, and as you say, discharging her meant providing her with substandard care. Had you done so, you would have violated a central ethic of your profession: that every life is of equal worth (even the lives of those who deny that tenet), that nobody should come to unnecessary harm owing to a caregiver’s decision.

The reason you can discharge someone who poses a serious threat of violence to others in the facility is, roughly, that if we face a choice between seriously endangering Jamie and seriously endangering Alex, and Jamie is the source of the danger to Alex, we should prefer the threatened person to the threatener. We’re essentially choosing between bad medical outcomes; in a clinical setting, knives should be wielded only by surgeons. That wasn’t the situation you faced. Hate speech produces what some legal scholars would deem a “dignitary affront”; and a dignitary affront, however much we deplore it, is not a medical crisis. Your primary brief wasn’t to calibrate the harms done by hate speech to the climate of your workplace. It was to ensure your patient received appropriate care, whether in your hands or others’.

Let me note, too, that the freight of words is affected by who’s speaking them. Patients — perhaps as a result of sepsis-associated delirium or certain neurological disorders — may not be in control of their speech; people who are subject to Tourette-syndrome-related coprolalia should not be denied medical treatment because their words make clinicians uncomfortable. And your patient? She had a problem with substance use and employed language that is, increasingly, stigmatizing of the user. She had no power over the clinicians who attended to her and to whose decisions she was subject. One indication of her lack of status is that your hospital’s risk managers evidently decided that the institution could safely eject her without being held accountable for the consequences. Though they didn’t intend to mete out a punishment that might have amounted to a death sentence, the risk managers effectively put the hospital ahead of the patient.

The duties of medical professionals are demanding. In wartime, a medic can have the responsibility of saving the life of a wounded enemy soldier, even if the soldier has just killed one of that medic’s friends. The fundamental clinical imperatives — evolved, collectively, over generations — shouldn’t be hastily set aside. Clinicians have duties of care to patients, even odious ones. And the more serious the likely consequences of refusing care, the larger the burdens they should be willing to accept.

My elderly mother began talking to a romance scammer on social media a few months ago. He claims to be building a bridge in South America and has asked her for money to support the project. She has given him tens of thousands of dollars — her entire savings. Given the convoluted stories she has told me, I have no doubt this man is scamming her, and she and I have fought about her continuing to talk to him. I love her, and it really upsets me that this man defrauded her of her money! Here is the thing, though. She talks to him via internet chat twice a day, and it genuinely makes her happy! She is the happiest I’ve seen her in a long time. She has had few friends over her life as well as disappointing romantic partners, and this is someone she actually enjoys talking to. Her savings are gone, and I think she will continue to use her Social Security and pension income to pay her bills. That is, I don’t think she will give this man much money in the future. Should I keep trying to persuade my mom to stop talking to this man, given that I think the “relationship” may end once the money flow stops, and she may feel very sad about the ending? Should I be worried about her physical safety if she stops giving this man money? Our arguments are really bad, and she definitely prefers I stop talking about it altogether. Name Withheld

A lot has been published about romance scams, including by law enforcement, and I don’t see that, in the usual course of things, its victims are in physical danger — the scammers often live in another hemisphere, for one thing. (You could contact the F.B.I. if you want further guidance.) But the financial and the emotional depredations are very real. Once the money stops, naturally, the scammers move on. There will be heartbreak ahead for your mother.

You’ve done what you can do. You have repeatedly pointed out the problem; you’ve warned her that the rewards of her relationship are predicated on a lie, and you no doubt have told her about the proliferation of such scams. She doesn’t want to go on talking about it. At this point, I don’t see what choice you have other than to let her be. As long as your mother remains competent, it’s up to her to manage her dealings with this man. There’s the minor solace that, as you indicate, the only ongoing risk is a continuing loss of relatively small sums of money, and she has enough to live on. It’s painful to watch someone you love being exploited, but you can’t lead her life for her.

To submit a query: Send an email to ethicist@nytimes.com; or send mail to The Ethicist, The New York Times Magazine, 620 Eighth Avenue, New York, N.Y. 10018. (Include a daytime phone number.) Kwame Anthony Appiah teaches philosophy at N.Y.U. His books include “Cosmopolitanism,” “The Honor Code” and “The Lies That Bind: Rethinking Identity.”

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