Observations Heads Up

Choosing who to treat

BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h5828 (Published 03 November 2015) Cite this as: BMJ 2015;351:h5828
  1. Krishna Chinthapalli, neurology advanced trainee
  1. 1Royal North Shore Hospital, Sydney, Australia
  1. kchinthapalli{at}bmj.com

When might it be justifiable to refuse to treat a patient?

Figure1

“Physicians are not bound to treat everybody who walks through their door,” except in emergencies, argued a US surgeon in 2004.1 He had proposed a resolution to the American Medical Association that doctors refuse treatment to medical malpractice lawyers in response to frustration at mounting malpractice insurance bills. Of course, the measure was denounced, with one wit responding, “What [he] is proposing is egregious, both hypocritically and Hippocratically.”

But are there circumstances in which refusal to treat (apart from emergencies) is justified if alternative care is available? One accepted scenario is refusal to see new patients if a practice is already full. The American Medical Association’s guidelines state that treatment can also be refused if it is beyond the physician’s competence or if it is “scientifically invalid.”2 Physical violence and danger to self may also be valid reasons, at least legally. In 1987 a precedent was set when a US doctor successfully used the 13th Amendment (the one abolishing slavery and involuntary servitude) to argue that he should not be forced to treat an abusive teenage dialysis patient.

Vaccine sceptics

Breakdown of trust is another reason but may mean differing views on a treatment. In the US about 20% of paediatricians have sometimes refused to continue being a child’s physician if parents persistently refused vaccination, despite education.3 This year’s measles outbreak in the US has led to some paediatric practices making it a policy to refuse any unvaccinated children. One argument is that such children pose a risk to themselves and others in the waiting room; another is that vaccine refusal suggests a lack of confidence in their physicians’ advice.

The American Medical Association guidance also says that treatment can be refused if it is incompatible with the physician’s personal, religious, or moral beliefs. Earlier this year a Michigan doctor gained international notoriety when she decided that she could not care for the baby of a lesbian couple (reason unstated) and arranged for another doctor to see them instead. There is no state law in Michigan prohibiting discrimination on the basis of sexual orientation. By contrast, in the United Kingdom the General Medical Council says that a physician’s personal views cannot affect the care they provide or arrange for a patient,4 and the UK’s Equality Act outlaws such discrimination.

Lifestyle factors are another reason for not treating. Active alcohol misuse is a contraindication to liver transplantation, but that decision is in national guidelines. Last year when vascular surgeons in Edinburgh refused GPs’ non-emergency referrals of smokers there was an outcry that it was “very God-like and highly unfair.”5

Soldiers and terrorists

On the battlefield, rules are clearer. Military doctors and doctors working for humanitarian organisations are covered by the Geneva Conventions and must treat all injured military personnel equally according to need. That was not always the case. (Ironically, Hippocrates himself rejected the Persian king’s pleas to help his plague stricken people, saying that they were enemies of the Greeks.) In 2005 the doctor Rafiq Sabir was arrested for agreeing to provide medical services to al Qaida forces in Iraq. He argued that it was his constitutional right to treat whoever he wanted. The jury believed that his actions amounted to more than just a physician’s duty—for example, he had allegedly pledged his loyalty to al Qaida—and he was imprisoned.

On the other hand, doctors at a Jerusalem hospital described treating an abdominal gunshot wound in a “leading member of Hamas” who was responsible for attacks on over 140 Israeli citizens. They asked in a medical ethics journal, “Is it in keeping with the fourth bioethical principle of justice to treat terrorists injured in the course of their terror activities, when they intentionally violate the basic principles of humanity and norms of society?”6 The answer would seem to be yes, however difficult that may be. One ethicist compared the case to that of Kafeel Ahmed, who had self inflicted third degree burns after he tried to attack Glasgow Airport in 2007.7 Ahmed died after being treated in intensive care for a month at a cost of over £100 000 (€140 000; $150 000).

What about doctors travelling independently to areas of conflict? In March nine UK medical students studying in Sudan entered Syria. One girl told her family that she wanted “to help wounded Syrian people,” but her father asked, “She was living in a land [Africa] which needs a lot of doctors everywhere. Why would she go all the way to Syria for volunteering?”8 The UK Home Office has only said that “fighting in a foreign war is not automatically an offence, but will depend on the nature of the conflict and the individual’s own activities.”8

In April the Australian doctor Tareq Kamleh said that he had joined Islamic State: “I have come here as there are locals suffering from normal medical conditions despite being surrounded by war, with an overt lack of qualified medical care.” He also appeared in an Islamic State video exhorting other Muslim doctors and nurses to join him, saying, “I saw this as part of my jihad.” The video is probably the basis for an Australian arrest warrant for joining and recruiting for a terrorist organisation. In July the Medical Board of Australia suspended his registration, but further details have not been released.

Choosing who to treat can be just as controversial as choosing who not to treat.

Notes

Cite this as: BMJ 2015;351:h5828

Footnotes

  • Competing interests: I have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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