Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether medical ethics allow you to fire an "extremely unpleasant" patient.
Yes: 75%
No: 25%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in with an excerpt from his book, :
Physicians in private practice have broad latitude to choose which patients they treat, as long as they do not discriminate on the basis of protected statuses like race or religion. This freedom is subject to the criticism that physicians are generally sheltered from market forces by the government -- through various mechanisms (e.g., limitations on medical-school class sizes and residency positions, retraining requirements for physicians educated abroad, etc.) that keep the number of doctors artificially low and, hence, fees artificially high. Having the talent to practice medicine is not enough to acquire a medical license or hang up a shingle; one must also meet lengthy and complex credentialing requirements designed to constrain entry into the field.
Since doctors do not operate in a free market, but rather as part of a protected guild, some commentators argue they should have charitable service obligations connected to their licensure. However, no such mandates exist. This contrasts with the duty of hospitals, which under EMTALA, the Emergency Medical Treatment and Labor Act of 1986, must stabilize every patient who comes through their doors.
Once a patient is already under the care of a particular physician, certain safeguards do exist to shield that patient from abandonment. As a general principle, a doctor can "fire" a patient as long as she affords the patient reasonable time and opportunity to find another provider. In psychiatry, for instance, 6 months is generally considered an ample interval to arrange alternative care. Usually, doing so is not difficult.
Yet some patients, for a variety of reasons, will face practical challenges in managing such a transition. Sometimes, a patient's mental status or healthcare literacy will prove so limited that she cannot be expected to find a new provider on her own. A patient suffering from dementia, for example, should not be asked to seek a different neurologist unaided. Under such circumstances, the original provider may be expected to assist with the transfer of care.
A very small number of patients find no alternative options. In one high-profile 2009 case, Grady Memorial Hospital in Atlanta closed a dialysis clinic that served many undocumented immigrants who were ineligible for treatment elsewhere. The ensuing court battle saw some of these patients repatriate, others move to states with more lenient Medicaid policies, and a few rely on hospital emergency rooms for urgent dialysis.
Much like the hypothetical case presented last week, a dialysis patient in California with severe addiction and behavioral problems, Brenda Payton, was "fired" by her dialysis clinic for unruly behavior, even though no other provider would accept her. A California appeals court ruled in favor of her doctors in 1982. While such a precedent is not legally binding outside of California, it may offer guidance to courts in other states.
Whatever the doctor ultimately decides about his patient in our hypothetical case, he can take comfort in knowing that courts and professional associations, while they generally look unfavorably upon doctors who abandon patients recklessly or for pecuniary gain, have historically been sympathetic in cases where a patient's conduct was both egregious and relentless.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases: