Ethical dilemma

Education and debateDealing with racist patientsDoctors are people tooCommentary: A role for personal values … and managementCommentary: Isolate the problemCommentary: Courteous containment is not enough

BMJ 1999; 318 doi: (Published 24 April 1999)
Cite this as: BMJ 1999;318:1129

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Mary Selby is lucky to be concerned about a racial incident from ten years ago!1 My experience is much more current than that; shouted racist epithets are common in this part of the country and it is possible, depending on the clinical environment to experience incidents involving patients which turn 'racial' three or more times a year. Many of us cope easily with minor, and sometimes major verbal abuse from the 'ignorant'. I find the best reaction to common racism in general practice, the wards, clinics is to ignore it and be professional. There are, however, dangers in 'using personality' as Julia Neuberger suggests and 'remaining courteous' as Pippa Gough advises; both may encourage the patient to lodge a complaint on some clinical grievance. Charles Easmon's attempts to isolate the problem show that the racist abuse is merely part of an 'everyday culture'. However some differentiation should be made between the racist views of the 'ignorant', which tend to be petty, if unsettling pricks, from those 'who should know better'. The former tend to be transitory - unless violence is involved. The latter is the precursor of the institutional racism of the NHS, manifested in the major, minor and trivial disadvantage suffered by ethnic minorities in dealing with bodies like the GMC, and in the culture of the royal colleges, defence organisations, and other administrative or institutional bodies.2 Those familiar with colonial and apartheid discourse will recognise some of the excuses; where the victims 'standards', 'temperament', 'cultural knowledge (bad loser etc.) becomes the issue. Not surprisingly many prefer not to complain or 'play the race card'; the stress involved in making a futile complaint and the resultant backlash are deterrents to most mortals.3

I find 'perceived' racism from peers of similar education - those with knowledge of the history of the British Empire and its legacies, like doctors, administrators, lawyers etc. is much harder to deal with. I use 'perceived' because this is often the reaction when one complains, despite the gradually accumulating figures to the contrary.4 Until 'educated' racism diminishes and the 'educated' educate the 'ignorant', the ignorant variety will thrive.5

Yours sincerely

John Lwanda
Gailes Park

Bothwell, Glasgow G71 8TS


1 Selby Mary. 'Dealing with racist patients'. BMJ 1999; 318: 1129 - 31

2 ODA News Review, Issue No. 17. Vol 5, May/June 1998.

3 Ruggiero KM and Taylor DM 'Why minority group members perceive or do not perceive the discrimination that confronts them: the role of self esteem', Journal of Personality and Social Psychology 72 (2): 373 - 89, 1997 Feb.

4 Esmail A, Everington S. 'Racial discrimination against doctors from ethnic minorities'. BMJ 1993; 306: 691 - 2.

5 McPherson W. 'The Stephen Lawrence inquiry'. London: Stationary Office, 1990.

Competing interests: None declared

John Lwanda

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Dear Editor

In response to "Ethical dilemma:Dealing with racist patients" BMJ No 7191 24 April 1999 p.1129-1131

I would like to recount my experience of a racist patient I encountered as a GP trainee (in those days) and my chosen response. While dilly-dallying in the reception area killing time between surgeries I was privy to a conversation between the receptionist and a patient on the telephone wishing to make an appointment. An appointment was offered with me-and on hearing an ethnic minority name, the patient's response obviously shocked the receptionist, who nevertheless stood her ground and arranged the appointment as first offered. The receptionist then recounted to me that the patient's response to being told my name was "Is he a Paki...?" accompanied by some protestations. The receptionist looking both embarrassed and shocked, apologised profusely and felt unsure whether she had acted correctly in continuing to make the appointment with me. I reassured her it was exactly as I had wanted.

On encountering the said patient later that afternoon, I proceeded with the consultation as if any other, but perhaps if I am honest, with more attention to detail, eye contact and trying harder to establish a good rapport. Having completed the consultation satisfactorily (at least as I thought with smiles on both sides) as I proceeded to see her out of the door I confronted her with her racism-- "Oh and by the way you were right, I am a Paki...".She had hit the nail on the head with my ethnic origin but not my gender. This opened up the conversation to excuses and apologies on the part of an obviously embarrassed patient. My aim was not to embarrass the patient but to enlighten her and to impress that, although I was aware of her racist views, this in no way prejudiced me toward her.

We encountered each other on subsequent occasions with no hint of animosity obvious between us.

My point is that a stance against racism has to be made, but honesty, subtlety and tact must be the key, not condemnation.


Dr Selma Malik Retainee in General Practice Nuffield Road Medical Centre Cambridge CB4 1GL

Competing interests: None declared

Selma Malik

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12 May 1999


Selby et al describe a not uncommon problem of having to deal with an extremely racist patient 1. Gough rightly points out that under many Trust policies this would be an assault on a member of staff. We should not expect to work in a hazardous environment; just because physical injury does not occur it does not mean that harm hasn’t happened. Easeman regrets that there are no effective sanctions against a patient who continues his racist abuse. The authors do not appear to be aware of the Public Order Act 1986. In Section 17 of the Act Racial Hatred is defined as "Hatred against a group of persons in Great Britain defined by reference to colour, race, nationality (including citizenship) or ethnic or national origins." This means a group which was "a segment of the population distinguished from others by sufficient combination of shared customs, beliefs, traditions and characteristics derived from a common or presumed common past, even if not drawn from what in biological terms was a common racial stock in that it was that combination which gave them an historically determined social identity in their own eyes and those outside the group" 2. Section 18 provides that it is an offence to use "threatening, abusive or insulting words or behaviour, … if having regards to all the circumstances racial hatred is likely to be stirred up thereby."

As to the question of intent the Act states that this is absent "if he did not intend his words or behaviour to be, and was not aware that it might be threatening, abusive or insulting." Hence, once the patient has been made aware that his words are threatening, abusive or insulting, he has no defence against a prosecution under the Act and he could be informed that he is committing an offence and that the police may be called. Of course whether a charge is preferred or not lies outside the hands of the Health Authority, unless they take upon themselves a private prosecution.

Dr M E J Wise Specialist Registrar in Adult Psychiatry Roundwood Resource Centre Harlesden Road LONDON NW10 3RY

1 Selby, M. "Dealing with Racist Patients" BMJ Volume 318; 1129-1131, 24 April 1999.

2 Archbold Criminal Pleading, Evidence & Practice. Richardson. Sweet & Maxwell, London 1998.

Competing interests: None declared

M E J Wise

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Dear Sir

Your set of articles on dealing with racist patients (BMJ Vol. 318, page 1129 - 1132) touches on an important topic which is not isolated to the behaviour of patients.

We currently run a one day evaluated course on how to appoint doctors without discrimination. Some months ago a senior consultant in a local hospital pointed out in the middle of the course that he had no interest whatsoever in what the law said. He stated that he was simply not going to have any foreigners or for that matter any women in his department.

In our other training courses we do not normally challenge frankly dysfunctional behaviour. Our strategy is to let the rest of the group handle the problem. In this case we were nonplussed when despite ample opportunity, neither the female consultants nor those from ethnic minorities who were present said a word. In fact they seemed to agree. At the end of the course one of the consultants from an ethnic minority came to thank me for the course but then asked why we bothering to put on such a course as he could not understand why we were not keeping these jobs for our own children.

Many of the Royal Colleges now insist that consultants attend a course on the law relating to discrimination before being allowed to sit on an interview panel. It is interesting to note that none of these Colleges have insisted on a course with a proper validated evaluation. Despite the fact that training without evaluation is not setting standards, it is just paying lip service to them. If we are to exclude frankly racist individuals, and colleagues who are prepared to collude in their behaviours the College must insist on validated assessment of knowledge skills and attitude not just require people to attend a course.

Competing interests: None declared

Chris Bulstrode

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Racist patient hurt the doctors from overseas. Overseas doctors in UK particularly asians are very rudly passed racist remarks by the patients. Most of the time these remarks are very much unexpected and really heart breaking for the doctor. Doctors almost never react for ethical and proffessional reasons. Many asian doctors even leave the country without even completing there training. I dont want to go into details of individual incidences faced by me and my asian collegues. But this matter needs attention as the asian doctors are humanbeings too.

Competing interests: None declared

Zulfiqar Ali Kango, Cardiologist in Pakistan Army

Armed Forces Instiyute of Cardiology

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Difficult to admit; difficult to change

Dear Editor

I felt quite heartened by the article which highlighted a very common but yet silent problem within the NHS. Dr Selby's account reminded me of a similar experience during a previous post:

A forty-five year old English female patient, with a mild anxiety disorder, was assessed by myself in outpatient's clinic and was to be followed up a few weeks later. To my surprise, the following week, the team secretary telephoned to inform me that the patient had called to cancel and had requested to be seen specifically by the consultant. As some patients wish this occasionally I thought no more of it and agreed. Later that day a red-faced receptionist, from appointments, told me that this patient had actually requested to see a white doctor whom she felt would be more understanding of her needs. Graciously this patient did not express a preference of gender. Suddenly I felt alone and was unsure on how I should react and how to proceed.

Subsequently I discussed this issue with a number of other non-white colleagues and was surprised about the regularity of certain themes. Firstly, they all had experienced similar circumstances with patients. Secondly, there was uniform uncertainty on how to deal with such a problem. And thirdly, there was hesitancy in discussing the problem with senior colleagues for fear of being asked for the "evidence" or being branded a "trouble-maker", inept or weak.

I feel the different perspectives in Dr Selby's case highlighted two main themes. One was that silence in the face of racism is unacceptable. At best it does nothing to stem the unpleasantness, at worst could be deemed as complicity by on-lookers (other staff or patients). The second is that there is a need for guidelines on how to handle such cases which I suspect are very thin on the ground within Trusts. If they do exist they are certainly not publicised.

I hope that you will keep highlighting this topic as the more we are able to discuss these issues the more quickly we, as a body, will be be able to come to terms with the existence of racism and learn to deal with these cases firmly and fairly.

David Oyewole Specialist Registrar in Psychiatry

South Kensington and Chelsea Mental Health Centre 1 Nightingale Place London SW10 9NG

Tel:(0181) 746 8000 Ext 6056 email:

No competing interests

Competing interests: None declared

David Oyewole, Specialist Registrar in Psychiatry

South Kensington and Chelsea Mental Health Centre, London SW10 9NG

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To look back at the 20th Century is to fear what happens when people are “just following orders”, and Pippa Gough is right to condemn this defence of acquiescence to prejudice and abuse. However, I feel uneasy when she writes “How much easier this doctor would have found the situation if there had been a clear organisational policy setting out the action to be taken in the situation described”. It might not be easier at all and it could contradict the “just following orders” point. Suppose the policy was that treatment should be withheld from an abusive patient and the doctor’s personal conviction was that treatment should never be withheld, no matter how repugnant or wrong was a patient’s behaviour? She should still follow the dictate of her own conscience, in defiance of “organisational policy”.

Dr. Selby, whose conscience has troubled her for ten years, has shown some courage in exposing a true dilemma, to which none of the solutions is easy. However, I agree with all three commentators that nothing in a professional relationship precludes one from answering gratuitously expressed views by speaking one’s own mind fearlessly, as well as preventing an individual patient from offending or hurting others.

Competing interests: None declared

Ed Cooper, Consultant Pediatrician

Newham General Hospital, East London

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I had a complaint made against me whilst working in Accident and Emergency as a Senior House Officer by the widow of a chap who had died from an MI. I was upset by the fact that the chap had died irrespective of the rights and wrongs of what was clinically done. I can appreciate the grief of the widow and why she was angry and how she could perceive why we hadn't done our best for her husband. What made the complaint worse to bear were her repeated comments that my history taking and clinical competence were in doubt merely because of my Asian name. I have never met her. I am born in the UK, speak with a public school accent and am British qualified. I was stunned by her suggestions of being sent back to "my own country", "not being able to understand good English", amongst other comments. I found that it honestly started to destroy any empathy I may have had for her and the complaints started to grow a new ugly head. I know she was angry but why did all of this bubble up from her conciousness. Would my mame always indicate my competency. As a general practitioner recently I removed a patient from my list immediately on the first racist expletive when no apology was forthcoming. I have the luxury of doing this at present. For how much longer? when an Asian GP in Birmingham in 1995 started screening his new patients for racist views, there was an outcry. My question is why? Shahid Dadabhoy

Competing interests: None declared

Shahid Dadabhoy, Principal in General Practice

107/109 Chingford Mt. Rd. Chingford, London E4 8LT

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It is clear,Mary Selby still panders to the view that professional courteousness to her patients outweighs the much foughtout rights enacted under the Race Relations Act 1976,and subsequent legislation such as the Protection from Harassment Act 1997.The comfort and assurance that she has given to an overtly racist patient,is another classic example of the double standards practiced by the medical profession.Even over ten years after the Race Relations Act,Mary Selby's reaction to overt racism has been a smile(admittedly nervously),and she still asserts that it was professionally correct.Thus,it is not clear whether Mary Selby is genuinely interested in race relation,or seeking self-publicity through the BMJ.However,she may draw some comfort from the BMA Chairman's latest view in the April issue of the News Review that,"discrimination doesn't take place within the BMA and we have been successful"!.

Competing interests: None declared

J B Ilangaratne, none


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