Understanding the "Difficult" Patient.

James Groves opens his 1978 foundational article, "Taking Care of the Hateful Patient," thusly, "Admitted or not, the fact remains that a few patients kindle aversion, fear, despair, or even downright malice in their doctors." Groves understood his article as pulling back the curtain on an experience that physicians had but that few dared discuss without shame. His taxonomy of four types of "hateful" patients: clingers, entitled demanders, manipulative help rejectors, and self-destructive deniers may still be instructive. However, the intervening years have revealed that this taxonomy does not adequately capture the nuances present when patients are described as "difficult." This issue of Narrative Inquiry in Bioethics situates this complexity. Different kinds of providers in a variety of healthcare delivering institutions have offered accounts of their own interactions with so-called difficult patients. In each of these stories, the providers tell the reader how the providers were transformed through these interactions: what they learned about their patients, what they learned about patient care, what they could have done differently or better, and what lessons they have taken with them into subsequent encounters.

Is Trust Enough? Anti-Black Racism and the Perception of Black Vaccine "Hesitancy".

In this article, I offer a preliminary exploration of the heavy lifting that the word "trust" is doing in questions about Black distrust of medicine and what, if anything, comes from it. I also offer an account of why questions like, "Why don't Black people trust vaccines?" are not only the wrong questions to ask but also insulting, and I go on to provide a Black feminist analysis of racial injustice in medicine-an analysis that does not center a notion of trust. I begin by arguing that implicit in these questions is a pathologizing of Black people-the idea that there is something wrong with Black people rather than something wrong with the conditions within which Black people exist. The sense that there is something wrong with Black people both further disadvantages them and ignores the role that health care institutions have played and continue to play in fostering a climate of distrust. I show that even attempts to explain distrust fail to adequately capture the harms committed against Black people, even if such efforts gesture at institutional responsibility. I sketch out what is important about trust but also briefly discuss why trust may not be the answer to the problems that Black people face in health care encounters.

Empathy and structural injustice in the assessment of patient noncompliance.

Empathy is generally considered important because it is linked to prosocial helping behaviors. To the extent that humans are thought to be social creatures, empathy is regarded as an important component of our general well-being. Meanwhile, empathy skeptics argue that empathy is not as important as its proponents believe. While there is philosophical debate about the appropriate place for empathy in moral judgment, empathy is a taken-for-granted, good-making feature of moral deliberation in healthcare. In this paper I offer an account of empathy and a critique of its moral significance before thinking specifically about the role that empathy plays in medicine. Finally, I offer a hypothetical case to show that in order to fully appreciate the skeptical position, empathy's role in health justice should be understood in the context of structural injustice. Although I ultimately defend the importance of empathy in healthcare environments, I show that any conception of empathy in healthcare should take seriously reasons for skepticism about empathy, notably its susceptibility to bias against disfavored groups.

Bioethics, Race, and Contempt.

The U.S. healthcare system has a long history of displaying racist contempt toward Black people. From medical schools' use of enslaved bodies as cadavers to the widespread hospital practice of reporting suspected drug users who seek medical help to the police, the institutional practices and policies that have shaped U.S. healthcare systems as we know them cannot be minimized as coincidence. Rather, the very foundations of medical discovery, diagnosis, and treatment are built on racist contempt for Black people and have become self-perpetuating. Yet, I argue that bioethics and bioethicists have a role in combatting racism. However, in order to do so, bioethicists have to understand the workings of contemptuous racism and how that particular form of racism manifests in U.S. healthcare institutions. Insofar as justice is part of the core mission of bioethics, then antiracism must also be part of the mission of bioethics.

Intersectionality in Clinical Medicine: The Need for a Conceptual Framework.

Intersectionality has become a significant intellectual approach for those thinking about the ways that race, gender, and other social identities converge in order to create unique forms of oppression. Although the initial work on intersectionality addressed the unique position of black women relative to both black men and white women, the concept has since been expanded to address a range of social identities. Here we consider how to apply some of the theoretical tools provided by intersectionality to the clinical context. We begin with a brief discussion of intersectionality and how it might be useful in a clinical context. We then discuss two clinical scenarios that highlight how we think considering intersectionality could lead to more successful patient-clinician interactions. Finally, we extrapolate general strategies for applying intersectionality to the clinical context before considering objections and replies.

Bioethicists Can and Should Contribute to Addressing Racism.

The problems of racism and racially motivated violence in predominantly African American communities in the United States are complex, multifactorial, and historically rooted. While these problems are also deeply morally troubling, bioethicists have not contributed substantially to addressing them. Concern for justice has been one of the core commitments of bioethics. For this and other reasons, bioethicists should contribute to addressing these problems. We consider how bioethicists can offer meaningful contributions to the public discourse, research, teaching, training, policy development, and academic scholarship in response to the alarming and persistent patterns of racism and implicit biases associated with it. To make any useful contribution, bioethicists will require preparation and should expect to play a significant role through collaborative action with others.