Views & Reviews Personal View

Allowing patients to choose the ethnicity of attending doctors is institutional racism

BMJ 2014; 348 doi: (Published 04 February 2014) Cite this as: BMJ 2014;348:g265
  1. Nadeem Moghal, associate medical director, George Eliot Hospital, College Street, Nuneaton, Warwickshire CV10 7DJ, UK
  1. nemoghal{at}

Nadeem Moghal reflects on a case in which a hospital accepted the request of the parents of a patient that care should be delivered by only a white doctor

On 22 April 1993 the black teenager Stephen Lawrence was murdered by a gang of people, some of whom were finally convicted in 2012. The deficiencies in the police investigation led to the Stephen Lawrence Inquiry, known widely as the Macpherson report, which defined the phrase “institutional racism” as “the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people.”1

This concept continues to be debated, particularly by police services, the focus of the Macpherson report. The definition is intricate, nuanced, and an advance in our understanding of our society. It is relevant to every organisation, private and public. It is a definition against which individual and organisational behaviours can be tested and healthcare services are no exception. NHS organisations have equality and diversity policies in place to comply with the law, and related mandatory training. Yet neither policies nor training were enough in a situation I experienced. This happened in this millennium in a hospital where I used to work. No names are needed because this is about how organisations might mature to understand and use the concept defined by Macpherson.

The story is that the parents of a child patient refused to have care delivered by black or other minority ethnic doctors; the request was phrased a touch more colourfully. The patient needed the specialist expertise available in tertiary hospitals. The clinical director concluded that because of the nature of the disease and the clinical need of the patient, the parents’ request would be enabled. Attendance at the clinic was planned to ensure that the patient saw one particular white British doctor.

The clinical team, which included doctors of South Asian origin, knew of this arrangement. On one occasion the patient seemed to be acutely ill, forcing the white doctor to check who was working in the assessment unit before deciding to see the patient because of the diversity of staff on the unit at the time. The arrangement continued for more than a year. There was an assumption that the rest of the clinical team accepted this arrangement on the grounds of clinical need. However, when the arrangement was revealed to others outside the specific service in question, as a supposed example of good decision making in a difficult situation, the reactions ranged from “this is no different from a female patient requesting a female doctor” to “this is the first time in my professional career I have felt defined and judged by my ethnic origin rather than my professional capability.”

After a difficult process, including requests for a reversal of the decision (including from me), which unexpectedly led to a board level inquiry, the medical director told the family that care would be provided by staff regardless of their ethnicity. The family relented.

What can we conclude? There are limits to patient choice. Seniority and senior leadership does not necessarily confer a failsafe moral compass. Our colleagues can unwittingly make decisions that damage other colleagues. And when racists are confronted they may ultimately relent.

But might this have been a moment in the organisation’s history when it behaved in an institutionally racist way? The decision to enable racist parents to determine who was to deliver their child’s care based on ethnicity was to effectuate the racist views of a racist. That does not necessarily make the people who gave effect to the racists’ views racist themselves. But such conduct could be seen, when reflecting back on Macpherson’s definition, as symptomatic of “the collective failure of an organisation to provide an appropriate and professional service,” not to the patient but to fellow colleagues, “because of their colour, culture, or ethnic origin.” Can institutional racism be seen or detected in the decision making processes that enabled the arrangement?

Does the decision reveal “attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness”? The key word is “unwitting” but the impact that such thoughtlessness has can be considerable. In this case, enabling the racist can be seen to have “disadvantaged minority ethnic people”—professional colleagues of minority ethnic origin not only in the particular specialty in question but throughout the organisation.

Any organisation might find it hard to accept that it had behaved in an institutionally racist way but the Macpherson definition allows an understanding and creates an opportunity to strengthen the policies of public and private institutions, adding to diversity training, with the aim to make the enabling of racist requests a never event. This type of enabling has happened before,2 and will happen again unless leaders grasp the definition and provide the right narrative.

The right outcome was eventually reached because of the courage and tenacity of those—including me—who stayed the course, but it was a difficult journey professionally and personally. I will always believe that what had gone on was a worthy subject for internal whistleblowing. The key lesson is that immediately confronting and standing up to racists rather than enabling them must be the first step to building equitable organisations. Organisations and especially their leaders must learn; Stephen Lawrence has much to teach us all.


Cite this as: BMJ 2014;348:g265


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.