Intended for healthcare professionals

Observations Ethics Man

Dealing fairly with racist patients

BMJ 2019; 367 doi: (Published 19 November 2019) Cite this as: BMJ 2019;367:l6575
  1. Daniel Sokol, medical ethicist and barrister
  1. 12 King’s Bench Walk, London
  1. daniel.sokol{at}
    Follow Daniel on Twitter @DanielSokol9

Clinicians should be able to exercise judgment

Racism is an odious human trait. It is also a major problem in a healthcare system in which 19% of NHS staff are from a black and minority ethnic background.1 A Pulse survey of GPs in 2018 found that 75% of GPs from such a background had experienced racism from patients.2 Hospital staff too are faced with outward displays of racism, from name calling to requests for a clinician of a particular ethnicity, prompting a message from the health and social care secretary for England earlier this month that racist abuse would not be tolerated.34 Racist attacks against NHS staff are also on the rise.4

It is against this lamentable background that, on 4 November, North Bristol NHS Trust launched its “Red card to racism” campaign. Any offending patient first gets a verbal warning, a “yellow card,” then, in the event of a repeat incident, withdrawal of treatment, a “red card.”

The campaign’s sentiment is laudable, and in most cases an overtly racist patient should be told that their behaviour is unacceptable. When and how this is done will depend on the circumstances. It may have to wait until an acute medical situation is resolved, an intoxicated patient regains sobriety, or stormy tempers calm.

Though well intentioned, the yellow and red card system’s simplicity may come at the cost of fairness. In the 2019 Rugby World Cup, before issuing a card the on-field referee would consult the off-field video referee to examine in detail the circumstances of the suspected offence. Will there be such rigour before clinicians reach for their yellow or red cards? Given the potential legal, ethical, clinical, and financial significance of a decision to refuse or withdraw treatment, will the patient have an opportunity to challenge the decision? Will there be an investigation and appeal system? The card system may work if all racist patients were uncomplicated bigots, but what if the patient has dementia or mental illness? What if the patient is of limited intellect or cognitively impaired?

There may also be specific reasons for a patient’s hatred of a particular race—such as a rape or other trauma inflicted by a person of that race—that while not excusing the racist behaviour may render the ordinary sanction disproportionate. And what if the racist patient is a minor? Should responsibility depend on age or the maturity of the child?

Matter of interpretation

What is racist can also be subject to interpretation, and what merits a red or a yellow card won’t always be clear cut.

There are situations when a patient’s racist behaviour justifies a refusal to treat, as long as the patient is medically stable and not in immediate danger. The General Medical Council’s duty to “make the care of the patient your first concern” is not absolute and should be balanced against the moral and employment rights of the clinician to be free from racism in the workplace. However, a patient’s racist behaviour should not automatically lead to a sanction or abandonment at a time of medical need.

What to do with an overtly racist patient should depend on the facts of the case, on the patient’s and the medical circumstances, the nature of the racist behaviour, the reasons and motivations for the behaviour as far as they can be reasonably ascertained, and what if anything can be done to resolve the problem.

Clinicians should be permitted to exercise their judgment in deciding what to do. Whatever action is taken, affected staff should have access to psychological support to counter the ill effects of racism on morale and wellbeing.


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.