Eyeworld

OPHTHALMOLOGY BUSINESS 110 October 2015 by John D. Banja, PhD Doctors refusing care to patients: What are the limits? dicated, without giving the patient reasonable assistance and sufficient opportunity to make alternative arrangements for care." Of course, this worry is especially pronounced in rural or sparsely populated areas where specialty care, such as an oph- thalmologist's, may be hard to find and the "fired" patient finds himself left in the lurch and getting progres- sively worse. Ultimately, the gravity and prognosis of the patient's condition are going to be key considerations. If dismissing the patient would not foreseeably result in any harm to him or her, then a successful lawsuit against the doctor would seem very unlikely because there are no dam- ages (although the patient might sue for discrimination as discussed be- low). But once having started treating a patient, a physician should have very compelling reasons for "firing" that individual should the patient's care needs continue. Also, note that Dr. Cassell's sign seems to refer to potential or prospective patients. He'd be very foolish to inquire about a patient's voting preferences in the middle of his treating him for pros- tate cancer and then halt it on the spot if the patient revealed he voted for Obama. Historically, though, physi- cians have enjoyed a robust right to choose which patients they will or will not treat. Yet even here there may be exceptions such as when a physician is compelled by statute (or just good sense) to treat certain patients whom he or she would prefer not to. For example, consider a second scenario in the form of a "conscien- tious objection," perhaps akin to Dr. Cassell's ideologically based reluctance to treat Democrats. In 2008, the California Supreme Court ruled (in North Coast Women's Care Medical Group v. San Diego County Superior Court) that Guadalupe Benitez, a lesbian who wanted intrauterine insemination, had a right to that treatment that out- weighed Christine Brody, MD's conscience-based objection to pro- viding it. Nevertheless, the Court's ruling allowed Dr. Brody to refer Conditions that obligate care versus ones that don't W ho can forget the Florida urologist, Jack Cassell, MD, posting a sign on his business door shortly after the Affordable Care Act was passed in 2010 that said: "If you voted for Obama … seek urologic care elsewhere"? I chuckled when I heard about it, but you can bet the American Medical Association (AMA) was not amused. Section 9.012 of the Code of Medical Ethics of the AMA's Council on Ethical and Judicial Affairs states that, "Under no circumstances should physicians allow their differences with patients or their families about political matters to interfere with the delivery of high-quality professional care." But who says physicians are bound by the AMA's ethical opinions? I would bet Dr. Cassell thought his announcement was unimpeachably ethical. But was it legal or did it amount to blatant discrimination for which he could face some kind of sanction from his state licensing board? What about his refusing oth- er potential patients he might not like? And what about the national debate on whether or not pediatri- cians should refuse to treat unvacci- nated children for fear of a measles outbreak from the pediatrician's office? Over the years, I've studied and discussed these questions in my ethics courses with student health professionals, and I recently reviewed some of the latest litera- ture on the subject. Based on this literature, I created Table 1, with the caveat that I'm not a lawyer and none of what I assert here should be taken as legal advice. Nevertheless, unless some very specific conditions occur that create exceptions, the ta- ble is probably relatively accurate in terms of categorizing patients who can be refused care outright; patients who probably should be provided care; and patients who fall into a gray zone where case specific details will determine the extent to which they can obligate their physician (or healthcare facility) to provide care. For the remainder of this article, though, I want to discuss 4 items that seem important for physicians to consider before they refuse or discontinue caring for a patient. The first and most important one involves the possibility of patient abandonment via a refusal of care. If a physician has begun treating a patient, law and ethics are rather emphatic that he or she should not dismiss the patient if discontinuing care might leave the patient significantly worse off. If a physician "fires" a patient such that 1) the patient's condition worsens as a 2) direct result of the treatment discontinuation, and 3) a reasonable attempt to find another physician to care for the patient fails, the "firing" physician might indeed be sued for abandonment and damages result- ing from the treatment discontin- uation. Section 10.01 of the AMA's ethical opinions says it nicely: "The physician may not discontinue treatment of a patient as long as further treatment is medically in-

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