Case Scenario

A female colleague in my clinic recently retired, and her patients were transferred to the care of two other physicians, one of whom is a man. One of my retired colleague’s patients is L.P., a woman in her fifties who has been treated in my clinic for nearly a decade. L.P. has requested that her care be assigned to the female physician, with the explanation that she has always had a female physician and that she feels more comfortable discussing her health with a woman. Although the transfer is possible, the remaining female physician in my clinic is already overburdened, whereas the male physician to whom this patient was reassigned has multiple open spaces on his patient panel. Does my clinic have an ethical obligation to honor this patient’s request for a female physician?

Commentary

Many patients have personal preferences regarding their choice of physicians. These may include personal factors such as the physician’s race, ethnicity, religion, gender, sexual orientation, or age. The literary critic Anatole Broyard, who confessed to harboring his own biases when choosing doctors, famously wrote that “to be sick brings out all our prejudices and primitive feelings.”¹ These patient preferences, and requests to accommodate them, occur on a continuum from those that our society views as reasonable to others that are considered pernicious.² Some preferences may be grounded in specific personal experience and prove clinically relevant; for example, a patient who is the victim of a race-based hate crime might have trouble engaging with a physician of the same racial background as the perpetrator. Other requests, often shaped by historical context and group identity, reflect subjective levels of patient discomfort. For instance, a Black patient might request for a referral for a Black mental health professional because the patient believes that a White mental health professional cannot meaningfully understand the patient’s life experiences. Similarly, a Palestinian patient might raise concerns about seeing an Israeli physician, or a veteran of the Vietnam War might object to being cared for by a Vietnamese-American physician. At the extreme, such requests may reflect outright animosity toward specific groups based on false beliefs about integrity or competence. Barring rare cases of clinical necessity—such as a patient who has psychosis who harbors a delusion that nurses of a certain background are poisoning them—the canons of medical ethics generally forbid accommodating animus-based requests. Under some circumstances, accommodating such requests might violate federal law in light of protections against discrimination laid out in the Civil Rights Act of 1964.³ Health care professionals may even have a moral duty to educate the patient that such discrimination is ill-founded and will not be tolerated. Unfortunately, higher-income or influential patients are often able to make such choices through access to private physicians. Thus, many ethical and legal limitations restricting the choice of a physician affect only marginalized or low- and middle-income patients.

GENDER

Evidence suggests that overall, both male and female patients prefer physicians of their own gender.⁴ The strength of preference varies considerably by patient gender and physician specialty. A strong association exists between female gender and a preference for female primary care physicians.⁵ These differences may be related to differences in communication style between male and female physicians.⁶ They may also reflect different cultural values regarding what is considered appropriate for gender roles and when physical contact between individuals of different genders is permissible, given that preferences are stronger for certain interventions than others.

Gender-grouping practices are often more broadly accepted than those involving most other demographic-based attributes. Our society tolerates, correctly or incorrectly, a range of social conventions based on gender segregation, such as assigning patients to rooms in hospitals and nursing facilities. Even the Supreme Court has imposed a lower bar for laws that make distinctions based on gender than those that do so by race or religion.⁷ Furthermore, requests for female physicians may have a positive societal significance in contradistinction to requests for male physicians because women historically have been marginalized in medicine. From a professional and organizational perspective, preference for a female physician may be interpreted as empowering, supporting women with expanded opportunities that may help reverse a legacy of discrimination. Honoring requests for male health care professionals could, in this context, be interpreted as merely reinforcing the status quo. An exception might apply in a female-majority field such as obstetrics, where overwhelming patient preferences for female physicians could potentially deter men from pursuing careers in this specialty.