Health care workers are facing increasing levels of violence, aggression, and harassment in the workplace, including discriminatory refusals of care based on race, religion, and other markers of difference. UHN Bioethicists affiliated with The Institute for Education Research (TIER) have developed a decision-making tool to help health care workers respond to discriminatory patient requests—supporting staff while maintaining patient-centred, ethical care.
Although these discriminatory incidents are becoming more common, many hospitals lack clear, consistent guidance on how to respond. UHN’s Caregiver Preference Guidelines, developed in 2007, helped leaders assess whether patient requests conflicted with institutional policies. However, the health care system has since expanded to include more diverse care settings, such as rehabilitation and complex continuing care. In addition, the sociopolitical landscape has shifted, with increased awareness of systemic racism and the need for greater attention to workplace safety. The original guideline no longer addresses the complexity or urgency of today’s challenges.
In response to this need, UHN’s Department of Clinical and Organizational Ethics revised the original guideline through a rigorous quality improvement project. The revised guidelines, called the Patient Bias and Preferences Guideline, are a more robust and legally grounded framework tailored to UHN’s clinical context. Informed by interviews with 27 clinicians, policy reviews, and consultations with clinical and organization groups—such as Legal Affairs, Inclusion, Diversity, Equity, Accessibility, and Antiracism (IDEAA), and patient partners—the five-page decision-making tool guides health care workers through six key decision points:
● Does the patient have urgent medical needs, and are they capable of making treatment decisions?
● Are there reasonable, non-discriminatory reasons for the request (e.g., religious, cultural, or trauma-related)?
● Is the request based on the clinician’s trainee status?
● Does the request violate the Ontario Human Rights Code?
● Who is the requester (e.g. the patient, a family member, or another party?)
● Is the clinician willing to continue providing care?
Based on how these questions are answered, the guideline outlines next steps such as initiating a manager-led discussion with the patient, assessing the need for accommodations, determining whether the clinician should be reassigned, or escalating the situation through institutional supports. This structured approach ensures that responses are consistent, respectful, and aligned with human rights and workplace safety standards.
By integrating ethical, legal, and psychosocial principles, the revised framework provides practical guidance that balances patient needs with the rights and well-being of health care workers and trainees. This framework offers a timely and actionable resource for fostering safer, more inclusive care environments.
Dr. Claudia Barned, project lead and corresponding author of the article, is an Education Investigator at The Institute for Education Research and a Bioethicist in the Department of Clinical and Organizational Ethics at UHN. At the University of Toronto, Dr. Barned is an Assistant Professor and an Affiliate Scientist at the Dalla Lana School of Public Health, an Associate Member of the School of Graduate Studies, and a Member of the Joint Centre for Bioethics.
This work was supported by UHN’s Department of Clinical and Organizational Ethics, with operational support provided by UHN Foundation.
Barned C, Nwafor A, Heesters AM. Navigating discriminatory requests and refusals of healthcare workers: A Canadian-based inpatient hospital algorithm. Nurs Ethics. 2025 Sep 6. doi: 10.1177/09697330251374153.