“‘Why have you come so late in the day?’ I asked weightily, to appease my conscience.

‘Sorry, doctor,’ replied the figure in a gentle, pleasant bass voice. ‘The snowstorm’s a terror. Help me up, I’m afraid. Couldn’t help it, begging your pardon, sir.’

‘A polite man,’ I thought to myself with pleasure. I liked the figure very much, and even his thick red beard made a favorable impression on me. His beard was clearly the object of considerable care and attention. Its possessor not only combed it but even anointed it with a substance which a doctor, even after such a short spell in the country, could identify without difficulty as clarified butter.’ […]

When I had finished examining the patient I was delighted by him. After all the incoherent women and frightened adolescents who twitched with horror at the touch of a metal spatula, after that morning’s affair of the belladonna, the miller was a sight for my sore, university-trained eyes. The miller talked sense. What was more, he turned out to be literate and his every gesture was indicative of respect for the science to which I was devoted – medicine.”[1]

In Mikhail Bulgakov’s story “Black as Egypt’s Night,” the physician narrator encounters a miller who stands out among his other patients. With a neatly groomed beard, the miller is well-behaved, polite, and compliant. In a peasant society where literacy is rare, he can read and write, trusts in science, and believes in the physician’s competence. He acknowledges the inherent imbalance in the clinical relationship and respects it. Most notably, he “talks sense,” quickly earning the doctor’s admiration. However, the miller’s naïveté soon becomes evident when he suffers severe poisoning after ingesting his entire quinine prescription at once, in an attempt to hasten his recovery.

The anecdote from the semi-autobiographical collection of short stories, “A Country Doctor’s Notebook,” highlights how healthcare practitioners categorize patients based on nonmedical considerations. Similar to other professionals who encounter diverse people in fleeting interactions, doctors and nurses engage in spontaneous profiling to reduce uncertainty and determine the best course of action. Appearance, manners, speech, and behavior offer insights into a patient’s social and moral standing, shaping the practitioners’ expectations of them. This categorization is not immutable; as new information emerges, doctors may adjust their initial impressions, as demonstrated by the case of the seemingly wise, but ultimately naive, miller.

The moral evaluation of patients, a ubiquitous phenomenon, has been a subject of intense debate in medical sociology for nearly three-quarters of a century. Talcott Parsons can be credited with bringing this issue to prominence. His influential “sick role” model underscored the importance of affective neutrality in clinical interactions, asserting that a physician’s personal feelings towards a patient should be irrelevant to the objective treatment of their illness.[2] Despite their criticism of functionalism as a paradigm and a method of scientific inquiry, symbolic interactionists and other interpretivist researchers largely concurred with this view.[3] Nonetheless, their ethnographic studies shifted the focus from prescriptive to descriptive, emphasizing that in practice, moral evaluation breached the principle of affective neutrality, with adverse consequences for both the patient and the clinical relationship.

In this brief analysis, I explore the moral evaluation of patients in the emergency departments of public hospitals in Romania. More specifically, I discuss the structural factors that render the moral evaluation necessary, the ways in which it is practically accomplished, and the consequences it has for the patients subjected to the assessment, with a focus on Roma.

The reflection is grounded in long-term ethnographic fieldwork conducted in 2013 and 2014 at two Romanian hospitals: a typical county hospital (County) and a public hospital in a large municipality (City). Data were collected through interviews and informal discussions with doctors, nurses, and registration clerks (registratori medicali), as well as observation of naturally occurring triage admission interviews and analysis of electronic files and paperwork. During the research, I strove to maintain a partially insider status, which provided sufficient familiarity with the triage workers to establish and maintain their trust, while avoiding excessive closeness that could hinder me from asking questions that a full member would not dare to raise. The arguments presented in this paper are explored in greater depth in my recent book, The Moral Evaluation of Emergency Department Patients: An Ethnography of Triage Work in Romania (Lexington Books, 2023).

Emergency departments distinguish themselves from other medical facilities by their unique admission process. Instead of the typical first-come, first-served approach, patients are prioritized based on the perceived urgency and severity of their conditions. This categorization occurs at the triage station. While formal criteria and indicators for evaluating patients do exist, they are often not strictly followed in practice. Instead, triage staff engage in a comprehensive assessment process, which incorporates clinical signs, reported symptoms, and moral judgments, to determine the order of admission.  

Rationing admission

As a situated activity, the moral evaluation of patients cannot be divorced from the broader context in which it occurs. In the case of Romanian hospitals, the demand for emergency care surpasses the resources available to meet such needs. This predicament arises for a variety of reasons, including the inadequate provision of primary care, especially in rural areas; the obligation for the uninsured to pay out-of-pocket for family doctor’s services; the high fees of medical investigations in private labs and the difficulties in securing an appointment for those provided free of charge; and the widespread belief that emergency medicine is of a better quality than family medicine, among others. Most triage nurses whose work I have shadowed acknowledge the existence of structural problems in the organization of health care and admit that patients have pertinent arguments to prefer the ED to family medicine. At the same time, they consider that the practice is unacceptable because it contributes to escalating overall healthcare costs, diverts the emergency service from fulfilling its intended function, results in overcrowded emergency departments and overburdened staff, and ultimately proves detrimental to the patients themselves by fragmenting their care and providing symptomatic relief without addressing the underlying medical issues.

The second principal factor influencing the moral evaluation process is the policy governing admission to the ED. Access to emergency care cannot be denied to individuals seeking it, regardless of their presenting complaints. Solely upon examination does the physician possess the authority to redirect the patient to a family doctor or another suitable medical facility. This policy, which I have observed to be stringently adhered to at both hospitals, curtails the discretionary power of triage agents. Nevertheless, it does not entirely eliminate it. As street-level bureaucrats, nurses and clerks possess a degree of latitude in interpreting and implementing the policy in their daily practice. While not denying access, they frequently subject patients whose complaints are deemed incongruous with the emergency service’s mission to protracted waiting times, reprimands, and admonishments in an attempt to deter them from returning to the ED with similar health concerns. This punitive approach is supplemented by efforts to ‘educate’ patients, typically manifesting as recommendations to consult either the family doctor or general practitioners operating within the nearby polyclinic.

Inclusion and exclusion

As described above, the moral evaluation appears as a systematic effort on the part of triage staff to deter people from using the ED for health issues that lie beyond the perceived purview of the service. In other words, it serves as a vehicle for (indirect) exclusion. While this is often the case, my examination of triage interactions has also revealed numerous instances where patients exhibiting minor symptoms or chronic conditions did not experience the sanctioning typically associated with such presentations. By employing the constant comparative method advocated by grounded theory, I have identified two seemingly contradictory moral evaluation criteria: the legitimacy of the case and the reasonableness of the visit.

A presentation is deemed legitimate if it constitutes a ‘real emergency,’ that is a condition that is acute, severe, or potentially life-threatening. Nevertheless, during a typical day, only a relatively small proportion of all presentations to the ED fulfill this criterion, such as multiple traumas, accidents, chest pain, seizures, burns, allergic reactions, poisoning, and so forth. Far more prevalent are circumstances wherein the issue is persistent, tolerable, and devoid of immediate, critical risks. While such presentations threaten the smooth functioning of the ED, the reasonableness of the visit is also assessed in determining the perceived entitlement to care. A visit is considered reasonable if the patient has no alternative location to seek care due to circumstances beyond their control, such as residing in a remote village with inadequate primary care provision, and if the decline in health cannot be attributed to their personal actions. In other words, a reasonable visit constitutes an illegitimate presentation that does not incur sanctions of any kind from triage staff. The presence of this implicit, yet consistently employed, criterion during the initial case assessment signifies that moral evaluation is not intrinsically an exclusionary social process. Rather, it offers favorable treatment to certain patients while imposing punitive measures on others.

Entitlement to care is not the sole dimension by which presentations to the ED are appraised. Triage staff also consider the deservingness of care, which is inferred from the patient’s social characteristics, language, and demeanor. All else being equal, an individual who contributes meaningfully to society—through employment, involvement in child-rearing, or caring for an elderly parent—or adheres to prevailing social norms is deemed more deserving of emergency care than their counterparts.

The case of Romani patients

The triage workers’ evaluation of patients’ entitlement to and deservingness of care constitutes an effort to reconcile the rationing of access with moral judgments. Although the moral evaluation process encompasses both inclusionary and exclusionary aspects, these are not indiscriminately distributed across patient groups. Certain categories of patients are more likely to face exclusion, with the Roma population serving as a prime example.

Interviews with nurses and clerks reveal a consistently negative portrayal of Romani patients. The Roma are characterized as being prone to seeking ED care for the most trivial concerns, congesting the service and disproportionately utilizing its resources compared to other social groups. Furthermore, they are perceived as troublemakers who arrive at the hospital in large groups, exhibit improper behavior in waiting areas, demonstrate a lack of respect towards staff, and resort to aggression in order to expedite admission. Within the staff-devised hierarchy of merit, the Roma occupy the lowest position, as they are deemed free-riders of the healthcare system in much the same way they are considered to exploit the broader social system – receiving various benefits, such as guaranteed minimum income and child allowances, without reciprocating with any meaningful contributions to general well-being.

Pervaded by negative stereotypes, the characterization of Romani patients demonstrates a lack of consideration for the structural conditions impacting the ethnic community. For example, staff’s narratives fail to acknowledge the historical marginalization and oppression experienced by the Roma. Factors such as poverty, high unemployment rates, and disparities in educational participation are either disregarded or attributed to putative personal or collective deficiencies. Likewise, the social determinants of health are overlooked, as are the numerous barriers to accessing healthcare services. Consequently, the reasonableness of the visit is a priori denied to patients presumed to be of Romani origin.

This is not to suggest that every Romani individual seeking to utilize the ED is subjected to prolonged waiting, reprimands, and other forms of sanctioning. Despite the unequal power dynamics inherent in triage interactions, the moral evaluation process represents a collaborative endeavor. During admission interviews, patients have the opportunity to demonstrate their worth and assert their entitlement to the service. If Romani patients manage to persuade triage workers that their health condition is genuine or convincingly present themselves as morally deserving of care, they tend to be admitted similarly to patients of other ethnic origins. However, the negotiation process is more complex in their case. Nurses often subject Romani patients to micro-aggressions, such as attributing blame for the development of the medical issue or the delay in presenting to the ED, and subject them to intense scrutiny of their credibility and moral standing. While many Roma successfully navigate the moral evaluation process, their individual achievements do not alter the prevailing portrayal of their ethnic group as problematic.

In conclusion, the moral evaluation of patients can be viewed as a reaction by triage workers to the heightened demand for emergency care. Although the process is predominantly exclusionary in its outcomes, it is driven by moral considerations. However, the staff’s lack of structural competence results in some of the most vulnerable patient groups, such as the Roma, being disproportionately subjected to various forms of sanctioning, from micro-aggressions to unwarranted admission delays. Unwittingly, these practices perpetuate unequal access to healthcare services, further exacerbating health disparities along ethnic lines.

[1] Bulgakov, A Country Doctor’s Notebook, 47–48.

[2] Parsons, The Social System, 435.

[3] Glaser and Strauss, “The Social Loss of Dying Patients”; Roth, Timetables; Sudnow, Passing on: The Social Organization of Dying.