I was listening to talk radio the other day and somehow the discussion turned to a personal story that the host had heard from their friend [Note: I was unable to verify this story as it did not make any headlines]. The short version was that a Canadian primary care physician refused to care for a patient because that patient had become violent during several visits and threatened the safety of the doctor and the staff.

The panel discussion that ensued was interesting. Two of the panelists agreed with the doctor citing that no one should be forced into a situation where their personal safety or the safety of others is at risk. Two of the other panelists were not as supportive saying that it is a slippery slope because what one person may see as “threatening” others may see as “loudly advocating for yourself”. The Hippocratic oath was brought up a few times, as was the fact that in Canada, it is basic right as a citizen to receive care.

I thought it would be interesting to discuss this same topic with the HCLDR community. Under what circumstances is it okay for doctor to refuse to treat a patient? And how do we ensure this doesn’t happen on a whim?

Medical Guidelines – Canada

The College of Physicians & Surgeons of Alberta (CPSA), which regulates the practice of medicine in that province has the following guidelines:

Physicians maintain the right to discharge a patient if the patient is physically or verbally abusive, threatening or violent towards the physician, their staff members or other patients. The use of discriminatory language, including racial slurs, towards a physician or staff members is considered abusive and threatening.

CPSA’s standard of practice on Terminating the Physician-Patient Relationship in Office-Based Settings clarifies CPSA’s expectations. If the situation escalates and there is a perceived or real threat of violence, physicians should not hesitate to contact local law enforcement or facility security for additional support. The top priority is your safety, the safety of staff members and the safety of other patients.

It is not okay for any physician to feel unsafe in their practice—this includes physicians in rural communities where there are fewer options for patients to access care.

The CPSA also has clear guidelines that prevent physicians from terminating a relationship with a patient based on:

• age, gender, marital status, medical condition, national or ethnic origin, physical or mental disability, political affiliation, race, religion, sexual orientation, or socioeconomic status;
• poor lifestyle choices (such as smoking);
• failure to keep appointments or pay outstanding fees unless advance notice has been given to the patient;
• refusal to follow medical advice unless the patient is repeatedly non-adherent despite reasonable attempts by the physician to address the non-adherence; or

Medical Guidelines – US

In the US, the situation is bit more nuanced as physicians have more autonomy to make their own decisions. In an excellent NY Times opinion piece, Dr. Sandeep Jauhar had this to say:

The American Medical Association, for its part, is somewhat ambivalent on the issue. The organization’s code of ethics states that physicians have a responsibility “to place patients’ welfare above their own self-interest.” But it also recognizes that doctors are individuals with the right to free choice, stating that “physicians should have considerable latitude to practice in accord with well-considered, deeply held beliefs that are central to their self-identities.” At the same time, that freedom, the code says, “is not unlimited.”

A consensus exists among legal and bioethics experts that doctors can refuse to provide treatment in certain situations. For example, courts have ruled that doctors may refuse to treat violent or intransigent patients as long as they give proper notice so that those patients can find alternative care. Forcing doctors to treat such patients, courts have said, would violate the 13th Amendment’s prohibition on involuntary servitude.

Doctors may also refuse to provide treatment if it conflicts with good medical practice. Physicians in intensive-care units, for example, routinely limit treatment they believe will provide no benefit, especially in cases of terminal illness.

Ethical Challenge

In the case of a patient who is threatening the personal safety of the physician or their staff, I believe most people would agree that the physician should not be forced to treat them as long as doing so does not put the patient’s life at immediate risk. Outside of that, however, the waters get murky very quickly.

Should physicians be forced to perform a procedure that goes against their personal beliefs? What if those personal beliefs are based on something we would regard as “fringe”. It’s a quagmire and I, for one, do not feel I have enough expertise in bioethics to weigh in on this. I am also biased because of the way the Canadian healthcare system is structurally aligned (for the most part) with the Canadian Bill of Rights.

But since healthcare is fundamentally a human-to-human enterprise, I believe that there is room for people to exercise judgement in non-life threatening situations. However, if a physician’s inaction or refusal to treat a patient puts that patient at undue risk – that is a situation that I believe we need to avoid. I just don’t know how we do.

Join the HCLDR community on Tuesday August 29^th at 8:30pm ET (for your local time click here) when we will be discussing these questions:

• Q1 In what situations should a physician be allowed to refuse treatment to a patient? Are there any circumstances where it’s unacceptable?
• Q2 Does patient autonomy need to be balanced with a physician’s ability to refuse treatment?
• Q3 What impact does a physician’s refusal to treat a patient have on their reputation and trust (ie: from other patients who may learn of the refusal)?
• Q4 What needs to happen when a physician refuses to treat a patient? What should the organization do? What should the patient do?

References

Jauhar, Sandeep MD. “Can Doctors Refuse to Treat a Patient?”, New York Times, 13 May 2019, https://www.nytimes.com/2019/05/13/opinion/can-doctors-refuse-patients.html, accessed 29 August 2023

“AMA Principles of Medical Ethics”, American Medical Association, https://code-medical-ethics.ama-assn.org/principles, accessed 29 August 2023

“Terminating The Physician-Patient Relationship In Office-Based Settings”, College of Physicians and Surgeons of Alberta, 9 January 2014, https://cpsa.ca/physicians/standards-of-practice/terminating-the-physician-patient-relationship-in-office-based-settings/, accessed 29 August 2023

“Professional Obligations And Human Rights”, College of Physicians and Surgeons of Ontario, March 2015, https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Professional-Obligations-and-Human-Rights, accessed 29 August 2023

Hull, Sarah C. “Not so conscientious objection: When can doctors refuse to treat?”, Stat News, 8 November 2019, https://www.statnews.com/2019/11/08/conscientious-objection-doctors-refuse-treatment/, accessed 29 August 2023

Pirotte BD, Benson S. “Refusal of Care”, StatPearls, 24 July 2023, https://www.ncbi.nlm.nih.gov/books/NBK560886/, accessed 29 August 2023

Image Credit

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