Ethnicity, Class, Gender, and Paternalism

Doctors’ inclination to make decisions for patients is sometimes bolstered by doctors’ racist, sexist, or classist ideas. Doctors are not immune to common stereotypical ideas that label women as flighty, lower-class persons as lazy, and certain ethnic minorities as unintelligent or uncooperative. For example, Danielle Ofri  explains that once medical students begin working on wards, they quickly learn from their medical supervisors to use the term “status Hispanicus” for any Hispanic female patient who is considered too emotional or demanding. Such attitudes can lead doctors to believe nonwhite patients are less worthy of high quality care, less willing to follow medical advice, and less able to participate in decisions regarding their own treatment.

The attitudes may help to explain ethnic and gender differences in the treat- ments that doctors offer to patients. (Far less is known about class differences.) As Chapter 3 discussed, African Americans are considerably less likely than whites to receive transplants following kidney failure. Similarly, doctors more often offer needed treatment (including angioplasty, bypass surgery, chemotherapy, and antibiotics) to whites than to African Americans or other minorities, even when both groups have the same symptoms and insurance coverage. In addition, doctors often offer minorities only cheaper, less desirable treatments (e.g., amputating a dangerously infected leg rather than treating it with intensive antibiotic therapy). Similarly, most studies suggest that women are less likely than men to receive high-intensity treatments such as organ transplants and coronary bypasses.

Even when doctors want to provide equal treatment and to enable patients to make their own decisions, cultural barriers can make this difficult. When doc- tors and patients come from different cultures (or different social classes), doctors may well find it difficult to gain patients’ cooperation or understand patients’ beliefs or wishes. Cultural differences are probably greatest when Western-born doctors treat immigrants from non-Western societies. In these circumstances, even the smallest gestures unintentionally can create misunderstanding and ill will. For example, in her observations of U.S. doctors and their Hmong patients who had emigrated from Laos, Anne Fadiman found that when doctors conferred with a Hmong family, it was tempting to address the reassuringly Americanized teenaged girl who wore lipstick and spoke English rather than the old man who squatted silently in the corner. Yet failing to work within the traditional Hmong hierarchy, in which males ranked higher than females and old people higher than young ones, not only insulted the entire family but also yielded confused results, since the crucial questions had not been directed toward those who had the power to make the decisions. Doctors could also appear disrespectful if they tried to maintain friendly eye contact (which was considered invasive), touched the head of an adult without permission (grossly insulting), or beckoned with a crooked finger (appropriate only for animals). Taken together, cultural conflicts such as these may lead doctors to conclude that they can’t collaborate with such patients and so must make decisions for them.