Physician's freedom of choice: fact or fiction?

The public cherishes freedom to choose competent, caring, committed and safe physicians. (1) That right persists to some extent even in today's tightly controlled managed care organizations.

[ILLUSTRATION OMITTED]

But what about the other side of this coin? What about physician freedom to choose which new patients to accept? Does managed care restrict this right? And with or without managed care, are there some criteria for refusing to accept a patient that are ethical and others that or not?

Or did physician freedom of choice never exist in the first place?

Dr. King's dilemma

Leroy King, MD, general internist, is wondering if his contract would allow him to deny a potential patient access to his practice. Furthermore, King wonders if excluding patients from his practice would violate his professional ethic.

Should physicians have a process akin to credentialing and privileging that they use to accept some people as patients and deny others? If so, what sort of criteria should be used in this patient selection process? Or, do the physician's professional ethic and the ethics code state that all who come must be served?

The physician's right to choose

Physicians once claimed that no one has the right to force a doctor to care for a patient. The 1912 American Medical Association's code of ethics states that, except in emergencies, a physician "is free to choose whom he will serve." (2) The AMA further explained this position in a 1939 pamphlet. The physician's right to choose patients, the pamphlet opined, is simply the counterpart of a patient's right to choose a doctor. (3)

Other physician groups echo the same sentiment. The American College of Osteopathic Family Physicians (ACOFP) states in its code of ethics that, "The physician must have complete freedom to choose patients whom she he will serve. However, the physician should not refuse to accept patients because of race, color, religion, sex, or national origin." (4)

Along with statements about the right to choose patients, there are cautions against abandoning patients. The AMA's first code of ethics, written in 1847 at the time of the organization's founding, states that it is the physician's "moral duty ... not to abandon a patient." (5)

The ACOFP states that "the physician shall give due notice to the patient, family or those responsible for the patient's care when withdrawing from the case so that another physician may be engaged." (4)

Patient selection is about what happens before a physician/patient relationship is established. Abandonment and its institutional counterpart, dumping, are about what happens after a relationship has been established.

Some wonder if refusing to care for a person in need of medical attention is analogous to abandonment. Linda Haddad, a principal in the Pittsburgh health care law firm Horty. Springer and Mattern, says, "I certainly agree that physicians should be able to discharge patients from their practice following appropriate procedure."

Emphasizing that her comments are the views of a potential patient, not legal advice. Haddad says she's "not sure I agree that physicians can ethically decline to care for someone who needs their services. If physicians can ethically be selective might they refuse to see the indigent, the obese, smokers, people who ride motorcycles without helmets?"

That is a good point, but is abuse of a right by some people sufficient reason to deny that right to those who do not abuse it?

Ethicist Tom Murray, president of the Hastings Center, says, "The idea that an individual physician has the right not to enter into a physician-patient relationship is an old one, not applicable to all situations, and always contingent on the ability to find care elsewhere. Sometimes the chemistry doesn't work and in those cases it's just as well that the patient see another doctor."

Indeed, the key point is not whether or not the right of physician choice exists (it does), but that the right is not applicable to all situations. The AMA has never claimed the right to turn away a patient with a medical emergency. Haddad reminds us that the right of physician choice is not intended to imply that a physician accepts only those patients that it is convenient and enjoyable to accept.

And the claim of "complete freedom" made in the ACOFP statement is immediately rendered bogus by a list of unacceptable reasons for refusing to accept a patient.

Selecting without discriminating

Today the AMA code of ethics fully acknowledges the futility of claiming an absolute right to choose patients. In its ethical policy statement, "Potential Patients," (6) the AMA states that "physicians cannot refuse to care for patients based on race, gender, sexual orientation, or any other criteria that would constitute invidious discrimination."

Nor can physicians discriminate against patients with infectious diseases. That specific mention is a product of the AIDS age.

In addition, "physicians may not refuse to care for patients when operating under a contractual arrangement that requires them to treat (except when) patient care is ultimately compromised by the contractual agreement."

[ILLUSTRATION OMITTED]

AMA continues by listing times when it may be ethically permissible for physicians to decline a potential patient. Physicians may decline to accept patients when:

* The treatment request is beyond the physician's current competence.

* The treatment request is known to be scientifically invalid, has no medical indication and offers no possible benefit to the patient.

* A specific treatment sought by an individual is incompatible with the physician's personal, religious or moral beliefs.

References

1. Eustice C. "The right doctor for you: Make the choice carefully." About.com Web site article.

http://arthritis.about.com/cs/docpad/a/rightdoctor.htm.

2. Baker, RB and others. The American Medical Ethics Revolution. Boston: Johns Hopkins University Press, 1999, p. 347.

3. Economics and the Ethics of Medicine. Chicago: American Medical Association, 1939. p. 15.

4. Code of Ethics. Chicago American College of Osteopathic Family Physicians.

http://www.acofp.org/about/ethics/code_of_ethics.html.

5. Code of Ethics. Chicago American Medical Association, 1847.

6. Code of Ethics. Chicago American Medical Association. E-10.05, Potential Patients. Adopted June 2000. www.ama-assn.org.

By Richard E. Thompson, MD

Richard E. Thompson, MD, is adjunct instructor of ethics at Drury University, Springfield, Mo. and president of Thompson, Mohr and Associates, Previously, he was an adjunct instructor of ethics at the Ethics Institute. St. Petersburg College. St. Petersburg, Fla. He can be reached by phone at [phone] or by e-mail at [e-mail]

Author's note: As usual, this column purposely ignores the political and legal aspects of the issue of doctors refusing to treat certain patients. The focus of this column is specifically relevant ethical considerations without segueing into either a public policy debate, judgmental moralizing, or an amateur discussion of relevant legal issues.