Physicians and health care providers face many ethical challenges in their practice. One of them is the ethical dilemma of dismissing a patient from a practice. Dismissing a patient means terminating the patient-physician relationship, which can have serious consequences for both parties. For example, dismissing a patient may affect their access to care, continuity of care, trust in the health care system, and health outcomes. On the other hand, not dismissing a patient may compromise the quality of care, professional integrity, safety, and resources of the physician or the health care provider.
How should physicians and health care providers handle this ethical dilemma? What are the sources of ethical guidance that they can rely on? This essay examines the ethical dilemma of dismissing a patient from a practice and compares the AMA Code of Medical Ethics and the Ethical and Religious Directives for Catholic Health Care Services. It argues that dismissing a patient from a practice should respect their freedom and ability to choose their actions with an understanding of the consequences.
What does the AMA Code of Medical Ethics have to say about terminating a patient-physician relationship?
The AMA Code of Medical Ethics is one of the main sources of ethical guidance for physicians in the United States. It consists of nine principles and several opinions that address various aspects of medical practice. One of them is terminating a patient-physician relationship¹.
According to the code, physicians have a fiduciary responsibility to their patients, which entails an obligation to support continuity of care. However, there may be situations when terminating a relationship may be justified, such as patient noncompliance, fraud, violence, or inability to pay. In such cases, physicians must follow a careful dismissal process that includes:
- Notifying the patient (or authorized decision maker) long enough in advance to permit the patient to secure another physician
- Facilitating transfer of care when appropriate
- Providing information and assistance to the patient
- Documenting the reasons and process of termination
The code also states that physicians should not terminate a relationship for reasons that would constitute discrimination or interfere with access to care.
The strengths of the code are its clarity, consistency, flexibility, and enforceability. The code provides clear criteria and procedures for terminating a relationship that are consistent with the principles of medical ethics. The code also allows for some flexibility in applying the criteria depending on the circumstances and context. Moreover, the code is enforceable by the AMA and state medical boards, which can impose sanctions or disciplinary actions for violations.
The limitations of the code are its incompleteness, ambiguity, and variability. The code does not cover all possible scenarios or situations that may arise in terminating a relationship. For example, it does not address how to handle situations where a disability or bias is the reason for desiring to terminate the patient-provider relationship. The code also leaves some room for ambiguity or interpretation in some terms or concepts, such as “long enough in advance”, “appropriate”, or “justified”. Furthermore, the code may vary depending on the state laws or regulations that govern medical practice. These are excellent situations for a clinical ethicist to support the clinicians.
The Ethical and Religious Directives call us to care for all patients and steward healthcare resources
The Ethical and Religious Directives (ERDs) are another source of ethical guidance for Catholic healthcare providers in the United States. They are issued by the United States Conference of Catholic Bishops (USCCB) and reflect the teachings and traditions of the Catholic Church. They consist of six parts and 72 directives that address various aspects of healthcare ministry. Two of them are stewardship of health care resources² and care for all patients³.
According to the ERDs, Catholic health care providers have a duty to care for all patients regardless of their personal characteristics or circumstances. This means that they should respect the inherent worth and dignity of every person as created in God’s image and likeness. They should also uphold the moral principles that guide their actions, such as respect for life, conscience, cooperation, and subsidiarity.
The ERDs also state that Catholic health care providers have a responsibility to exercise stewardship of available healthcare resources in a way that promotes equity of care and dialogue with society. This means that they should allocate resources fairly and efficiently among all patients according to their needs and dignity. They should also engage in dialogue with other stakeholders, such as policymakers, insurers, or employers, to advocate for a just healthcare system that respects human life and dignity.
The strengths of the ERDs are their comprehensiveness, coherence, relevance, and authority. The ERDs cover a wide range of issues and topics that are relevant to health care ministry in the contemporary world. They also provide a coherent and consistent framework that integrates the theological, moral, and social dimensions of health care. Moreover, the ERDs are relevant to the challenges and opportunities that Catholic healthcare providers face in their practice. Furthermore, the ERDs have authority as they are issued by the USCCB and endorsed by the Vatican.
The limitations of the ERDs are their complexity, diversity, controversy, and applicability. The ERDs are complex and nuanced documents that require careful interpretation and application. They also reflect the diversity and plurality of opinions and perspectives within the Catholic Church and society. Some of the directives may be controversial or contentious among different groups or individuals. For example, some may disagree with the directives on conscientious objection, emergency contraception, or end-of-life care. Additionally, the ERDs may not be applicable or binding to all health care providers or settings. For instance, some may not identify as Catholic or share the same beliefs or values as the ERDs.
Compare and contrast the AMA Code of Medical Ethics and the Ethical and Religious Directives on dismissing a patient from a practice
The AMA Code of Medical Ethics and the Ethical and Religious Directives have some areas of agreement and disagreement on dismissing a patient from a practice. Both sources of ethical guidance recognize the importance of continuity of care and respect for patient autonomy. They also acknowledge that there may be situations when terminating a relationship may be necessary or justified. However, they differ in their criteria, procedures, and implications for dismissing a patient.
The AMA Code of Medical Ethics focuses on the individual patient-physician relationship and its fiduciary nature. It provides specific criteria and procedures for terminating a relationship based on professional standards and legal obligations. It also implies that dismissing a patient is a last-resort option that should be done with caution and compassion.
The Ethical and Religious Directives focus on the social dimension of health care ministry and its stewardship nature. They provide general principles and guidelines for allocating resources and caring for all patients based on moral values and social justice. They also imply that dismissing a patient is a complex decision that should be done with dialogue and discernment.
The arguments and evidence for each position can be evaluated based on their validity, reliability, consistency, and relevance. The AMA Code of Medical Ethics has valid arguments that are based on logical reasoning and empirical evidence. It also has reliable evidence that is based on peer-reviewed sources and expert opinions. However, it may lack consistency in some cases where its criteria or procedures may conflict with each other or with other ethical principles. It may also lack relevance in some cases where its arguments or evidence may not address the specific needs or circumstances of the patient or the physician.
The Ethical and Religious Directives have valid arguments that are based on theological reasoning and doctrinal evidence. They also have reliable evidence that is based on authoritative sources and magisterial teachings. However, they may lack consistency in some cases where their principles or guidelines may conflict with each other or with other moral values. They may also lack relevance in some cases where their arguments or evidence may not address the specific needs or circumstances of the patient or the health care provider.
Dismissing a patient from practice is an ethical dilemma that requires careful consideration and balance of various factors. Both the AMA Code of Medical Ethics and the Ethical and Religious Directives offer valuable insights and resources for physicians and healthcare providers to handle this dilemma. However, they also have some limitations and challenges that need to be addressed.
Practical Guidance and Questions to Consider Before Dismissing a Patient from Your Practice
Determining whether or not to dismiss a patient from your practice can be a daunting question. It should always be handled with care and respect the freedom of the patient. Clear communication is necessary to ensure that the patients understand the consequences for the actions they choose, e.g. not showing up for appointments, breaking behavioral contracts, etc.
Practical Guidelines
Before dismissing a patient from your practice, you should follow these practical guidelines:
- Communicate clearly and respectfully with the patient about the reasons, process, and consequences of termination. For example, you can explain why you are considering terminating the relationship, what steps you have taken to avoid it, what options the patient has to find another provider, and what will happen if they do not comply with your decision.
- Seek consultation or guidance from colleagues, mentors, ethics committees, or professional associations. For example, you can ask for advice from other physicians who have faced similar situations, consult with an ethics committee or a bioethicist on the ethical implications of your decision, or refer to the AMA Code of Medical Ethics or the ERDs for ethical guidance.
- Document thoroughly and accurately the details and outcomes of termination. For example, you can record the reasons for termination, the date and method of notification, the response of the patient, the transfer of care arrangements, and any follow-up actions or communications.
- Reflect critically and constructively on your own values, beliefs, biases, emotions, motivations, and goals. For example, you can examine your own feelings and attitudes towards the patient, identify any potential conflicts of interest or biases that may affect your decision, evaluate your own professional integrity and competence, and assess your own learning needs and goals.
- Learn continuously from your experiences, feedback, research, education, or training. For example, you can seek feedback from your peers or supervisors on your decision and its outcomes, review the latest research or literature on dismissing patients from practice, attend educational programs or workshops on this topic, or pursue further training or certification in ethics or communication skills.
Questions to Consider
Before dismissing a patient from your practice, you should also consider these questions:
- What are the reasons for dismissing the patient? Are they consistent with the ethical standards of the medical profession and the Catholic faith?
- What are the consequences of dismissing the patient? How would they affect the patient’s health, dignity, rights, and access to care?
- What are the alternatives to dismissing the patient? Are there ways to resolve the conflict or address the problem without terminating the relationship?
- What are the obligations of the physician and the health care institution to the patient? How can they fulfill their duties of care, respect, justice, and stewardship?
- What are the values and beliefs of the patient and the physician? How can they communicate and collaborate effectively and respectfully?
- What are the sources of authority for the physician and the health care institution? What does integrity and consistency look like in following them in their decision-making?
Opportunities to Collaborate with an Ethicist on This Topic
If you need further assistance or guidance on dismissing a patient from your practice, you can also collaborate with an ethicist on this topic. Some possible ways to do so are:
- Develop educational programs or workshops to enhance the knowledge, skills, attitudes, or behaviors of physicians and health care providers on dismissing a patient from a practice. For example, you can invite an ethicist to design or facilitate a curriculum or a session on this topic for your staff or students.
- Promote dialogue and collaboration among physicians, health care providers, patients, policymakers, insurers, employers, and other stakeholders to address the ethical issues and challenges of dismissing a patient from a practice. For example, you can involve an ethicist in organizing or moderating a panel discussion, a forum, or a conference on this topic for your community or network.
Conclusion
This essay examined the ethical dilemma of dismissing a patient from a practice and compared the AMA Code of Medical Ethics and the Ethical and Religious Directives for physicians and healthcare providers. It argued that dismissing a patient from a practice should respect their freedom and ability to choose their actions with understanding of the consequences.
Dismissing a patient from a practice is an ethical dilemma that requires careful consideration and balance of various factors. Both the AMA Code of Medical Ethics and the Ethical and Religious Directives offer valuable insights and resources for physicians and health care providers to handle this dilemma. However, they also have some limitations and challenges that need to be addressed. By following the recommendations and directions suggested in this essay, physicians and health care providers can improve their ethical decision-making and enhance their professional practice.
Call to Action
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