Dr. Weber is director, the Ethics Institute, University of Detroit Mercy, Detroit.
When a person in need of home care insists that the care provider be a particular race, how should a case manager respond? The particular ethical dilemma in the following case occurs with some frequency in the provision of home care in the United States, at least in some geographic areas.
A Case Manager's Dilemma
H. P. needs and is willing to accept care at home, but she insists that she does not want a black care provider in her home. M. J., H. P.'s case manager, needs to decide whether to make arrangements that specify a white worker or to tell the patient that the home care providers will not comply with this request.
M. J. has had such requests or demands before and has wrestled with them each time. She knows that some case managers do try to provide a home worker of the race requested. They argue that personal care is intimate and private and that compatibility with the care giver is an important dimension of a good patient experience. Patients, they conclude, should have a worker with whom they are comfortable.
Another possible reason to accede to a patient's request is that sending a worker to a home where he or she is not wanted places the worker at risk of racial insults or abuse. In this particular case, H. P. has made a major point of insisting that no black person come into her home; she might be capable of such harassment.
M. J. has heard and considered these arguments before. She is also convinced, however, that there is a fundamental injustice in not permitting someone to do a particular job simply because of his or her race. In the past, M. J. has always refused to honor requests for home care workers of a particular race. This time she decides she would like some assistance in thinking through this issue. She asks if the ethics committee or someone else can help clarify what her ethical responsibilities are. (This case is based in part on R. Kane and A. Caplan, eds., Ethical Conflicts in the Management of Home Care, Springer, New York City, 1993, pp. 205-206).
A Most Blatant Form of Discrimination
It is not surprising that M. J. and others in her situation often find it difficult to know how best to respond to a patient's request or demand for a home care worker of a particular race. Some ways of thinking about managers' responsibility to patients and workers may seem to suggest that a case manager should, in fact, comply with such requests. To do so, however, would be a serious mistake. It would be a fundamental assault on human dignity. The other concerns often expressed in cases like this do not, even when taken together, justify the use of racial criteria in making job assignments.
Preventing a worker from performing a particular job simply because of her or his race is a most blatant form of discrimination. When a factor like race — totally unrelated to the ability to do the job — is used as a basis for deciding who does what work, managers are saying that irrelevant and biased considerations will be permitted to influence work assignments. It is hard to imagine a more basic violation of worker dignity and of fairness in the workplace.
In the case above, H. P. is white and insists that no black worker be sent to her home. The issue would be the same, of course, if an African-American patient were asking that a white worker not be sent. As the case is presented, the issue is not that there is a communication problem or that there is a personality conflict between a particular patient and a particular worker. The issue is simple racial preference.
Several considerations are sometimes put forward to justify accommodating a patient's racial preference in home care work assignments. I want to respond briefly to four:
- Being a patient advocate
- Respecting cultural differences and the patient's idiosyncrasies
- Respecting patient privacy
- Protecting workers from unnecessary risk of harm
Patient Advocacy The use of racial criteria in making work assignments is not justified by an appeal to patient advocacy. To be a patient advocate is to seek to do what is best for a patient; it is to promote a patient's well-being and keep that concern from being subordinated to other less fundamental interests or considerations. This does not mean, however, that a patient advocate should accede to any and all patient requests. Especially when patient behavior or staff compliance with patient preferences may be harmful to someone else, it cannot be seen as justified simply because it may make the patient feel more comfortable. The patient is not the only person involved or affected.
A good manager would not allow a patient to subject a home care worker to sexual harassment. Nor should a manager allow a patient to determine the race of the home care worker. In both cases, being a patient advocate does not in any way justify abandoning basic ethical workplace standards. A violation of basic human rights is not acceptable even in the name of the important goal of patient benefit.
Respecting Differences The use of racial criteria in making work assignments is not justified by an appeal to respect for cultural differences or personal idiosyncrasies. In recent years, many providers have recognized that patients come from various cultures and backgrounds, and these differences should be respected. Furthermore, they recognize that individual differences should also be respected when possible, even when they strike others as being strange. We may think that someone else's way of thinking or behaving is odd, but we want to let people live according to their values as much as possible.
Respecting personal likes and dislikes is important, but not when such cooperation harms someone else. Wanting a home care worker of a particular race is not simply a matter of taste: It is a request that a manager apply a standard that is harmful and insulting. It is one thing to let patients live their own lives according to their own values; it is something else to allow them to dictate a violation of basic standards of justice and ethics.
Patient Privacy The use of racial criteria in making work assignments is not justified by an appeal to respect for patient privacy. The concern-for-privacy argument is that the home is part of the private sphere in a way that a healthcare institution is not. Although managers would not honor a request regarding the race of the nurses caring for a patient in a hospital, some think that the home may be different. The home is the place where people can really be themselves. In this context, it is sometimes argued, persons should be free to live their lives according to their own personal standards, even if their standards appear to be bigoted.
Most of us would agree, I think, that people should by and large be able to control who enters their own homes. When they engage a healthcare agency to provide care in their home, however, the home becomes a place in which professional services are provided. Just as one cannot say that professional standards of healthcare cease to exist when healthcare is taken into a private setting, so one cannot say that employment standards cease to exist when work is taken into a private setting. A manager cannot justify substandard healthcare because it is provided in a private home. Nor can a manager justify substandard employee treatment because an employee is working in a private home.
This same reasoning applies to another dimension of the privacy argument-that is, that the care provided by a healthcare worker in a home is very personal (e.g., bathing) and that a patient should be permitted to decide who is allowed to enter that realm of personal privacy. Personal privacy is an important consideration, but race is not relevant in this context.
Protecting the Workers The use of racial criteria in making work assignments is not justified by an appeal to the protection of workers from risk of harm. Sometimes, as in the case of M. J. and H. P., the argument is made that a patient's demands should be honored for the worker's sake, if not for the patient's. Again, there is an element of a legitimate concern here. Workers should not be exposed to unnecessary risk of harm. But if a patient's racial demands are acceded to, the worker is actually harmed. In the name of protecting workers, racial discrimination is being implemented. As the history of racism has shown, the desire to protect racial minorities from harm has often been the expressed rationale for limiting their opportunities. A denial of their human dignity is no way to protect persons.
Copyright © 1995 by the Catholic Health Association of the United States
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