Ethics of Refusing a Patient

Dr. Frederick Ross has decided that he will not continue to see patients that smoke cigarettes, and people are upset about this. Some very snarky commentators suggest that doctors will then not see people that eat too much cholesterol, or drive without a seat belt, or have other objectionable habits. What are the ethics involved?

Let us be clear that we are discussing an on-going doctor patient relationship. We are not talking about emergency treatment. Dr. Ross would quite rightly be chastised if he refused to treat someone for a broken leg because he found that person was a smoker. He would also be wrong to refuse to take on a patient that he discovered was a smoker. He must give that person time to take advantage of his advice, which presumably would be to quit smoking.

The whole point of the medical profession to help people get well, and advise them how to avoid becoming unwell in the first place. Dr. Ross seems to be suggesting that if people don't follow his recommendation to quit smoking, they are not serious about their health. He warned them back in December that this would happen, but only a handful have walked away. At least 30 have committed to stop smoking, and they still appear to his patients.

Doctors are busy people. Most have more patients that they really have time for, and waiting room times are legendary. If the patient isn't going to act in their own self interest, why should the doctor continue to waste time with them? That time would be better spent with someone that wants to get well, or has a condition the doctor can help them with. I think that Dr. Ross is on clear ethical ground here.

Does this reasoning extend to other un-healthy habits? Might a doctor refuse to treat an overweight patient that does nothing to control their weight? Refuse to treat a substance abuser?

The crux of the matter is that people have to take responsibility for themselves and their actions. Doctors don't cure people, they help people cure themselves. Yes, being overweight or a substance abuser is bad for your health. But no doctor is going to refuse to take someone as a patient because they are 10 kilos overweight. They wouldn't have many patients for one thing. For another, that 10 kilos is still within what most people would call normal.

But what about 100 kilos? Most would call that person grossly obese. Would a doctor be justified in refusing to keep them as a patient? This is a little more complex. This weight problem could be glandular, so the person needs the doctor to prescribe the appropriate medication to even have a hope of controlling the condition. If the patient takes the medication as prescribed, and is trying to cope with the problem, the doctor would be very wrong to abandon that patient. If the person didn't take the medication, and didn't follow any of the doctors instructions, then they have to take the consequence of those decisions. As Dr. Ross did, a doctor could abandon such a patient with a clear conscience.

Lets look at another common addiction, alcohol. There is some medical evidence that minor quantities have a mild beneficial effect. In moderate amounts, alcohol doesn't seem to be good or bad, although this varies between people. Even the most vigilant of doctors might not see any sign of alcohol use in these people, and they would be hard pressed to justify refusing to treat them.

An addict that hasn't hit bottom yet isn't going to admit they have a problem, and isn't liable to do anything about it no matter what their doctor says. Although the doctor might be seeing medical damage being done by the drinking, and could easily predict the damage to come,the patient might not notice, and probably doesn't care. Under these circumstances it could be argued that continuing to see the patient enables them to think that everything is OK. Refusing to see them might help point out what a dangerous course they are one, and might bring them to hit bottom sooner. Once the drinker admits they have a problem and starts to do something about it, that same doctor would be obliged to take them as a patient again.

I think Dr. Ross has done a good thing here. Doctors are not slaves obliged to treat anyone that comes before them. They are selling a valuable commodity; medical knowledge applied to one particular patient. They cannot refuse to sell that knowledge on monetary grounds, nor racial or religious grounds. But a patient that does not value this knowledge deserves to go without.