Refusal To Treat A Patient
Refusal To Treat A Patient
Refusal To Treat A Patient
Abstract: Refusal tohelp means for most people declining toaccept theduty totreat. Thereasons for refusing
tohelp and how wethink about these reasons from anethical and professional viewpoint are outlined
byconsidering ethical principles, anhistorical perspective, thelaw, societal contracts, medicine as amoral
enterprise, professional codes, aphysicians personal beliefs, reasons for refusing tohelp and physician
discretion. Refusing tohelp apatient is not consistent with theethical principle ofbeneficence, theconcept
oftheprimacy ofpatient welfare or theobligation oftheprofession tocare for thesick. However duty totreat
should not be exploited byinstitutions or place physicians incircumstances that they consider morally,
psychologically or physically unacceptable. Following theprinciple ofdistributive justice, physicians are
obligated toparticipate inthepublic debate toensure that all patients have their needs met bydeveloping or
improving health care systems and addressing thenew ethical questions that are likely tobe generated.
Key words: duty totreat, ethical obligation tocare for thesick, refusal tohelp
*This article is based on the lecture which was presented at the 36th Congress ofthePolishSociety ofInternalMedicine,
Warsaw, Poland, April 24, 2008
tice). Theprinciples ofprofessionalism outlined inthePhysi- could be held accountable for abandonment. Thus aphysi-
cianCharter, arecently formulated document though theef- cian cannot unilaterally break therelationship with apatient
forts oftheAmericanBoard ofInternal Medicine Foundation, without transferring care to another provider. The other ex-
American College of Physicians Foundation and the Europe- ception tothelack oflegal obligation totreat is theUSA fed-
anFederation ofInternalMedicine, published in2002 [2,3] eral American with Disabilities Act of 1991 which prohib-
include primacy ofpatient welfare as well as patient autono- its physicians from refusing tocare for patients onthebasis
my and social justice. ofadisability [9,10].
American Board ofInternalMedicine there is often away tosqueeze inanother person without
It is unethical torefuse totreat apatient solely ontheba- doing harm. Theprimacy ofpatient care puts this action
sis ofthat patients disease when thedisease is within thephy- above that of a tired physician. Nevertheless, these deci-
sicians area ofcompetence [10]. sions should be made as a result of physician discretion
and not through exploitation byaninstitution. Inadisas-
ter situation where there is overwhelming need, tough de-
American College ofPhysicians cisions must be made so as totreat those most likely tobe
Thedenial ofappropriate care topatients for any reason is able tobenefit.
unethical [10,13]. 3) Patient is hostile. Ifapatient cannot pay, does not follow
thecare plan, takes too much time, etc, there is no ethical
Association of American Medical Colleges justification for refusing tohelp and their may be alegal
Medical students, residents and faculty have afundamen- obligation once arelationship has been established tocon-
tal responsibility to provide care for all patients assigned tinue treatment. There are instances when a hostile pa-
to them, regardless of diagnosis. A failure to accept this re- tient poses aserious physical threat toeither thephysician
sponsibility violates abasic tenet ofthemedical profession or other health care personnel that may necessitate termi-
toplace thepatients interest and welfare first. Faculty mem- nating thepatient/physician relationship. Ingeneral how-
bers [should] model the professional behavior and attitudes ever, physicians and patients are best served byphysicians
expected [11]. using their skills of persuasion, tolerance, patience and
the patients option to seek another provider if there is
dissatisfaction oneither side. Beneficence and theprimacy
Personal beliefs ofpatience welfare should prevail whenever possible.
4) Physician has a moral or religious objection to the kind
Those who choose medicine as aprofession doso toserve
oftreatment thepatient is seeking. This issue has sparked
theneeds ofthesick. This action is grounded intheethical
great debate intheUS over thepast several years not just
principle of beneficence doing good and the ethical val-
for physicians but also for other health care providers such
ue of virtue doing what is right. We have all experienced
as pharmacists [10,12,14]. The topic is too big for this
the feeling of irritation when patients come late to appoint-
forum but suffice it to say that issues such as the abuse
ments, thesinking feeling when anextra person needs tobe
of public trust when physicians hold monopolistic licens-
seen urgently inanalready overbooked clinic, and thedespair
es and the threat to patient welfare must be considered
when woken one more time atnight knowing you must get
when physicians put their own personal beliefs or interests
up out ofyour warm bed. But wedowhat is needed because
above those oftheir patients. In2006, asurvey was con-
ofour empathy for thesick patient as well as apersonal un-
ducted in a random sample of 2000 practicing US phy-
derstanding that wewould feel worse ifwedid not doit. In-
sicians to understand their attitudes about physicians re-
cidentally weare usually rewarded byhaving helped aperson
fusing to provide treatments to which the physician ob-
or family indistress.
jects on moral grounds [15]. Of the 1144 who respond-
ed, 63% believed it ethically permissible toexplain moral
Physician discretion objections to a patient, 86% that a physician is obligat-
ed topresent all available and legal treatment options and
Physicians, being under no absolute obligation to care 71% that aphysician is obligated torefer thepatient toan-
for all persons in need or all the needs of an individual pa- other physician who does not object toproviding theser-
tient doinfact choose whom totreat and whom not totreat vice in question. These results show, however, that up
on a regular basis. The ethical implications of refusal to help to 100 million Americans may be being treated by phy-
vary with thereasons for not doing so. sicians who do not believe they have an obligation to re-
fer toanother provider under such circumstances. It would
Reasons for refusal tohelp seem that patient autonomy is threatened bynot being in-
formed about a physicians position on certain treatment
1) Physician is not competent. If a patient has a problem options. It would be inthebest interests ofpatients toen-
outside thearea ofphysician expertise interms ofknowl- sure that they are aware ofaphysicians attitudes and be-
edge or skills, inappropriate treatment may do no good liefs before seeking advice about certain controversial pro-
and could cause harm. cedures. Should theobjection be onthegrounds ofmedical
2) Physician or institution has no space or time or triage is futility, care should be taken bythephysician not toaban-
necessary when resources are limited. Ifall hospital beds don thepatient while helping them seek other advice.
are in use or an office schedule is full, harm could be 5) Physician is atrisk. Over thecenturies there has been aso-
caused to the needy patient and/or other patients from cietal expectation that physicians should care for thesick
disruption of optimal care systems. On the other hand, even in situations when their own life or health may be
SUMMARY
Refusing to help a patient is not consistent with the ethical
principle ofbeneficence, theconcept oftheprimacy ofpatient
welfare or theobligation oftheprofession tocare for thesick.
Although duty totreat should not be exploited byinstitutions
to place physicians incircumstances that they consider moral-
ly, psychologically or physically unacceptable, all efforts should
be made tofind alternative care providers. Following theprin-
ciple ofdistributive justice, physicians are obligated topartici-
pate inthepublic debate toensure that all patients have their
needs met bydeveloping or improving systems toallow this
tohappen. However such systems are likely togenerate new
ethical questions which wemust be prepared toaddress.