Is it Ethical to Withhold Medical Care Unless Patients Follow Doctors’ Orders?
“Hospitals Prescribe Big Data to Track Doctors at Work,” a July 12, 2013, article in The Wall Street Journal, describes a California health system that monitors physicians and grades them on the basis of what percentage of their patients meet certain metrics, such as a blood glucose level (as measured by HbA1C) of less than 8 percent.
But if some diabetes patients refuse to come in for visits, physicians can’t track their progress. If their blood sugar is elevated when they do come in, the measurement system gives the physician a black mark.
Dr. Keith Lee has found a solution to this problem. He refuses to give such patients long-term prescriptions. This forces them to come in for checkups in order to get new prescriptions. “I cut them short, and then they get the message,” he reportedly said.
This isn’t a case in which drug dispensing is tightly limited because the drug treatment has significant risks and requires higher than normal expertise to dispense safely. Nor is it a case in which a rude or abusive patient is impossible to deal with or threatening a physician with bodily harm. Judging from his reported statement, Dr. Lee is willing to use his prescribing power simply to make his patients visit on a regular basis so that he has a better chance of meeting his employer’s goals. Is treating patients this way in accord with the ethics of the medical profession as they have been traditionally understood?
Does your answer remain the same if it takes many hours for a patient to make a visit or if the patient has to miss large amounts of work? Does it change if the physician was refusing to treat a child unless his parents ensured that he had all recommended immunizations? What about a hospital refusing hip replacement surgery to an anti-abortion protestor?
A1C levels are known to vary with ethnicity, age, and alcohol consumption. There is some evidence that tight management of glucose control targets in people who have high A1C is associated with higher mortality risk, more hypoglycemia and slightly higher risk of adverse events.
“Dr. Lee is willing to use his prescribing power … so that he has a better chance of ***meeting his employer’s goals***. Is treating patients this way in accord with the ethics of the medical profession as they have been traditionally understood? (***mine)
No. (Even though that might be the right thing to do.) The answer doesn’t change with your variables. The focus can only be on the patient while not violating the law (and that can get touchy).
The physician can fire the patient as long as suitable care exists.
I disagree. I would say the answer is yes, it is ethical.
It is the owner’s business and he should be able to run it any way he wants. If people aren’t happy with the way they are treated they can go elsewhere.
Now, the problem is that the health care system is so screwed up that many people are completely “buyer immobile”, they can’t shop around. The problem is the regulatory handcuffs that keep the industry from being flexible and responding to consumer demands.
Of course, the free-market may not necessarily solve this problem, it will just accurately reflect the valuation of consumers. But if they foolishly ignore their doctor, they only affect themselves.
I think it all depends on the scenario we’re talking about. There is no cookie-cutter in anything for health care.
It really should be free market driven and that makes it ethical if they can go somewhere else if they don’t get that care.
Exactly. Each person decides what is best for them, no one size fits everybody.
JD and others. I think a few may have missed the asterisks in my response and the point between them. A physician treats a patient and not the one who pays the bill. Nor should he treat the employer’s needs.
“***meeting his employer’s goals***”
There is a difference between physician ethics and one’s rights. The question involved ethics which would also involve the motivation of the physician.
“No one size fits all” in the context used has nothing to do with physician ethics.
It would depend on the circumstances. How detrimental to their care is the non-adherence? Smoking and emphysema or smoking and lung cancer might be a case where non-adherence could prompt withholding care.
Obesity and hypertension may be another.
It is neither ethical; nor unethical. If the patient is paying their own bill, they have the right to do whatever they please. In my opinion their preferences are less important if they expect someone else to pay for their preferences.
Right. Because health care is largely provided collectively, neither the doctor nor the patient get any say. This is a problem.
…and that is why we keep losing freedom. It is logical to assume that if everyone is paying for it, then everyone should get a say in the decision-making. The only real solution is to stop having everyone paying for it.
“Dr. Keith Lee has found a solution to this problem. He refuses to give such patients long-term prescriptions. This forces them to come in for checkups in order to get new prescriptions. “I cut them short, and then they get the message,” he reportedly said.”
Creative. I don’t think that he’s doing anything wrong, he’s just responding to the situation.
Right. This is only one way to assure better responsibility from patients but it’s not the only way.
Actually, what is likely to happen is that his “non-adherent” patients w/ the out-of-goal A1cs will change providers, thereby improving this provider’s ratings.
I have read that in Canada FPs “interview” (by questionnaires) prospective new patients and avoid accepting onto their panels complicated, time-consuming multi-diagnosis (eg, morbidly obese elderly smoker w/ diabetes, etc.) patients.
Where do these patients go? The Canadian-equivalent of walk-in clinics.
This doctor is creating a hardship to his patients in both time and money. I am sure he receives a copay each time he sees a patient which increases his overall income. The patient has a loss of income and time while this doctor withholds medication the patient needs. With commercial insurance networks shrinking as they are it may be difficult or impossible to change doctors.
Very draconian.