A provider refuses to see a patient until she pays the balance due from a previous visit

Summary

Medical ethics

Core ethical principles [1]

Overview

Principles

• Autonomy
  • Provide sufficient information for the patient to be able to make their own decisions regarding their care (i.e., informed consent).
  • Honor the patient's choices to accept or decline care.
• Beneficence
  • Advocate for the patient and act in their best interest (fiduciary relationship).
  • May conflict with autonomy
• Nonmaleficence
  • Avoid causing injury or suffering to the patient.
  • May conflict with beneficence: The balance of risks and benefits must be favorable to the patient.
  • Frequently discussed in reference to drugs and surgical procedures
• Justice
  • Treat patients fairly and equitably.
  • Equity is not the same as equality.

Legal competence

Legal competence assesses an individual's global decision-making ability (e.g., relating to financial, property, and health care decisions), whereas decision-making capacity is a functional assessment that can vary depending on the situation. For example, a patient may have the capacity to choose between blood pressure medications but not to consent to complex surgery. [8]

Decision-making capacity

Overview [6]

• Definition: a patient's ability to understand and communicate a health care decision based on their preferences and values
• Key considerations
• Required components: All of the following are required for a patient (or their surrogate) to demonstrate capacity. [9]
  • Communication of a choice: the ability to clearly and consistently communicate the decision
  • Demonstration of understanding: the ability to comprehend the information provided, including the different options available
  • Appreciation of relevant facts: the ability to recognize and evaluate the facts relevant to the situation
  • Reasoning in medical decision-making: the ability to describe the thought process behind the decision

Decision-making capacity for low-risk medical decisions can be assumed if the patient demonstrates understanding during a conversation.

Identify and treat reversible causes of incapacity (e.g., delirium, infection, intoxication, medication) before assessing capacity.

Do not mistake pseudoincapacity (i.e., a lack of understanding due to insufficient patient counseling and/or use of jargon) or a decision against medical advice for lack of decision-making capacity. [9]

Shared decision-making [12]

• Definition: a process in which the patient and clinician work together to make a health care decision
• Indication: nonemergency situations in which there is clinical equipoise
• Goals
  • Patient empowerment by considering their values, cultural beliefs, and preferences when making a medical decision
  • Improved patient satisfaction and buy-in (e.g., medication adherence)

Three-step model for shared decision-making [13]

If a patient defers a decision, revisit the “decision talk” in subsequent conversations.

Surrogate decision-making [15]

• Definition: a model in which another person makes treatment decisions for the patient because they lack decision-making capacity and/or legal competence
• General
  • A surrogate may be appointed by the patient (e.g., medical power of attorney), legally appointed (e.g., court-ordered guardian), or next of kin (if no advance directive exists).
  • Advance directives or surrogates are only used if the patient has lost the ability to make their own decisions. [16]
  • Advance directives may be revoked by the patient at any time if they retain decision-making competence.
  • Surrogate decisions should be based on what the patient would have wanted.
• Hierarchy of decision-making [17][18]
  1. A mentally competent patient capable of making their own decisions
  2. Advance health care directive: prespecified legal instructions from the patient used to guide medical decision-making
     • Living will: a legal document in which individuals describe their wishes regarding their health care (e.g., to maintain, withhold, or withdraw life-sustaining care) should they become incapacitated
     • Durable medical power of attorney (health care proxy): a legal document through which an individual designates a surrogate to make specific health care decisions
     • Oral advance directive: an oral statement made by a patient regarding their preferences prior to incapacitation
  3. Next of kin
  4. Ethics committee or legal consult
• Caveats: if the patient's preferences cannot be determined and there is a disagreement regarding the course of action (e.g., the wishes of a designated surrogate who is not a family member conflict with the wishes of family members)

Oral advance directives may pose problems of interpretation, as oral statements are not as specific or easy to confirm as written statements. The validity of an oral advance directive increases if the patient has made an informed choice, the instructions were specific, and the directive was confirmed by multiple people.

Patients with decision-making capacity and competence have the right to provide or withdraw informed consent at any time (even during a procedure).

The Spouse ChiPS in: Spouse, Children, Parents, Siblings, other relatives/close friends (priority of surrogate decision-making)

Medical decision-making in pediatrics

Informed consent

Overview [23]

• Definition: the process of attaining the patient's authorization for a medical test, treatment, or procedure
• Key considerations
  • Ensure that there is sufficient time before the intervention for the patient to make a well-considered decision.
  • A patient with decision-making capacity is free to provide or revoke their consent at any time; it does not need to be in writing.
• Required components: applies to the patient or their surrogate [24]
  • Voluntariness: The decision must be made without coercion.
  • Capacity: Decision-making capacity must be demonstrated before consenting to the intervention.
  • Comprehension: The decision-maker must demonstrate understanding of the ramifications of the proposed intervention.
  • Disclosure: Relevant medical information regarding the intervention must be disclosed.

Obtaining informed consent [25]

Informed consent should be obtained by the health care provider performing the intervention.

1. Inform the patient of the benefits, risks, alternatives, and indications of the intervention and the nature of their illness, including:
   • Known complications and estimated risk of death and morbidity
   • Alternative interventions
   • The expected nature of the disease course without any intervention
   • If any aspect of the proposed intervention is experimental
2. Assess the patient's decision-making capacity; (e.g., using the teach-back method) and ability to consent voluntarily.
3. Document the decision that the patient (or their surrogate) has clearly articulated.

Use your BRAIN when obtaining informed consent: Benefits, Risks, Alternatives, Indications, Nature

Failure to obtain informed consent prior to performing an intervention may constitute negligence or battery. [26]

The amount of information shared when obtaining informed consent depends on the frequency and severity of the risks involved, e.g., less information needs to be disclosed for venipuncture than for cardiac catheterization. [25]

Exceptions to standard informed consent [27]

Difficulties in obtaining consent should not delay life-saving procedures.

Language and use of an interpreter [27][28]

• Discuss health care decisions with patients in terms they can relate to.
• Communicate in a language that the patient understands.
• Request an interpreter if you are unable to communicate with the patient in a language in which you can have a comprehensive discussion and assess the patient's understanding of the relevant information.
  • Both in-person and remote (e.g., phone, video) interpreter services are appropriate.
  • Communicating without an interpreter can result in patients unknowingly consenting to unwanted procedures, misunderstanding their diagnosis, and/or complying poorly with medical advice.
• For more information about particular instances of the use of medical interpretation, see “General concepts of patient counseling” in the “Patient communication and counseling” article.

Multilingual relatives are not acceptable alternatives to professional interpreters in the nonemergency medical setting.

Disclosure

Full disclosure [40]

• Patients have the right to full medical disclosure.
• Family members do not have the right to ask a physician to withhold information from a patient with decision-making capacity and competence without good reason. [41]
• Exceptions
  • The patient requests that the physician withhold information from them.
  • Therapeutic privilege: The physician determines that full disclosure would cause severe psychological harm to the patient (e.g., it may be reasonable to postpone disclosure of full diagnosis to a patient who is discovered to have multiple sclerosis who is having a concurrent major depressive episode with suicidal ideation due to divorce).

Confidentiality

Overview

• The physician is ethically and legally obligated to keep the patient's medical information (including information disclosed by the patient to the physician) confidential.
• Confidentiality upholds patient autonomyand privacy.
• The patient may waive the right to confidentiality (e.g., if an insurance company requests patient information or the patient allows the physician to disclose information to a family member).
• If the patient loses capacity, health information should be disclosed according to the patient's best interest (e.g., the physician will disclose relevant health information to friends, family, or the health care proxy to help guide medical decisions).
• Health care providers should make their best efforts to ensure the safety of patient information (e.g., patient information should not be discussed in public areas, even within the hospital setting).

Minimum necessary standard [48][49]

Patient privacy and permitted information disclosures

WAIT a SEC: Wounds, Automobile-driving impairment, Infections, Tarasoff decision, Suicidal intention, Elder abuse, Child abuse (cases that override confidentiality).

Access to patient health records [50]

Under HIPAA, patients have a legal right to obtain copies of their medical records within 30 days of submitting the request.

Electronic information safety

Reporting

Overview of common reportable diseases

Child protective services (CPS)

Foster care

Domestic violence [62]

• Definition
  • Any form of actual or threatened physical or emotional harm committed by one member of a household against another, frequently used as an extension power by the perpetrator against the person experiencing the violence
  • Intimate partner violence (IPV): any form of physical, emotional, or sexual violence that is carried out by a cohabitating or noncohabitating intimate partner against the other [63]

• General
  • Physicians may not report domestic violence without patient consent.
  • When a physician suspects domestic violence, they should speak privately with the patient, inquire further, and offer assistance.
  • If the patient refuses assistance, the physician should reiterate that they support the patient and are available to provide aid at any time.
  • See “Abuse” in “Ethically challenging situations” below.
  • See “Domestic violence” in the article “Sexual violence, domestic abuse, and elder abuse” for more details.

Malpractice, misconduct, and physician impairment

For more information about different types of errors leading to negligence, see “Medical error” in the article “Quality and safety.”

The 4 D's of malpractice: Duty (obligation to deliver proper medical care to the patient), Dereliction of duty, Damage to the patient, Direct cause of damage.

Physician misconduct

• Physician misconduct is any physician behavior that goes against the ethical principles of medical practice. [70]
• Physician misconduct can occur outside the established physician-patient relationships and thus does not always constitute malpractice.
• Examples of misconduct [70]
• Colleagues who suspect a physician of misconduct should report their concerns to the state medical board and, if the misconduct implies any legal liability, to the proper federal authorities. [71]

Conflicts of interest

Overview [77]

• Definition: A conflict of interest (COI) occurs when a physician's objectivity regarding their primary interest (i.e., patient welfare) is potentially affected by a secondary interest (e.g., personal financial gain).
• Minimizing COIs [78][79]
• Acceptable gifts and donations [78]
  • Gifts from patients that are small and do not have substantial monetary value (e.g., home-cooked meals, flowers, knitted quilts) ; [80]
  • Medical industry honoraria to attend medical education conferences
  • Industry-funded simple meals or social events
  • Remuneration for medical consultation for a pharmaceutical or medical device company
  • Industry-funded scholarships for travel to academic conferences by medical students or residents.

The physician must disclose all COIs to all affected parties and, in the event of a COI, refer patients to an unbiased colleague whenever possible.

Referral of patients

Research in vulnerable populations

Involuntary commitment

Use of social media by physicians

Physicians increasingly use social media and other internet resources for learning, networking, interacting with patients, and disseminating health care related knowledge. The following considerations can help ensure that their online presence aligns with professional ethics. [88]

Abortion and stillbirth laws

Examples of ethically challenging situations

Autonomy

• An adult patient refuses treatment based on religious beliefs.
  • Explain the treatment options and available alternatives.
  • Make sure that the patient understands the consequences.
  • Respect the patient's choice.
• A patient wants to try alternative medicine.
  • Identify the underlying reason.
  • Do not negate or devalue the patient's decision.
  • Evaluate for possible drug interactions, adverse effects, and safety.
  • Allow treatment integration if it poses no risk of harm to the patient.

Abuse

• A patient discloses abuse by a close partner.
  • Evaluate safety and the presence of an emergency plan for the victim.
  • Show empathy and willingness to provide continuous support.
  • Counsel and evaluate for psychological comorbidities.
  • Perform thorough documentation of abuse (the patient may want to take legal measures against their abuser).
  • Do not force the patient to leave their partner.
• A pediatric patient has an injury inconsistent with the caregiver's report.

Confidentiality

• Family members request information about the patient's health condition: Do not discuss issues with relatives without the consent of the patient.
• Family members request that the physician withhold diagnostic information from a patient.
  • Explore why the family members want to withhold this information.
  • Evaluate the extent of the information that the patient wants to receive.
  • Deliver the patient information according to their preferences.
  • According to therapeutic privilege, the physician may withhold information from the patient if disclosure increases their likelihood of causing self-harm.
• A patient with HIV refuses to inform their partner.
  • Encourage the patient to disclose the information to individuals they may have transmitted HIV to.
  • All cases of HIV must be reported to the local and state health departments.
  • If the patient refuses to inform their partner, the use of confidential partner notification procedures via the health department is encouraged.
  • For a more in-depth explanation of the legal nuances surrounding this issue, see “HIV” in “notification of diseases,” above.

Competence and decision making

• Parents refuse life-saving treatment for their child.
• A pregnant 16-year-old wants to have an abortion. [90]
• A 15-year-old wants to keep her baby against her parents' will.
  • Pregnant individuals have the right to decide to carry their infants to term, and to chose to keep the baby or put it up for adoption.
  • Provide practical information about all options.
  • Accept and support the patient's decision.
  • Encourage good communication between the patient and her parents to evaluate the options and arrive at an agreement.
• A 14-year-old girl requests contraceptives.
  • Offer advice on safe sex practices and prescribe contraceptives.
  • There is no need to notify parents to get consent.
• A patient's family insists on maintaining life support indefinitely despite evidence of brain death because the patient still moves when touched.
  • Carefully explain to the family that brain death is equivalent to death and it excludes any chance of recovery.
  • Clarify that the movements are only an involuntary result of spinal arc reflex.
  • Refer the case to the ethics committee regarding futile treatment and withdrawal of life-sustaining therapy.
• A father and 13-year-old son are found unconscious with internal bleeding after a car accident; the father is found to have a religious preferences card, which states that he declines blood transfusions because of religious beliefs.
• A patient asks for a non-emergency treatment or procedure that is in opposition to the physician's personal or religious beliefs.
  • Impartially inform the patient about all the options, in order to help them make an informed decision.
  • Respectfully explain that you do not perform the requested intervention.
  • It is mandatory to facilitate the transfer of care to another qualified physician.
• A patient is suicidal or homicidal.
  • The patient is considered to have impaired decision-making.
  • Assess the threat (organized plan, access to weapons).
  • Admit the patient voluntarily; admit involuntarily if the patient refuses.
  • If the patient produces homicidal threats, inform authorities and the threatened individual (Tarasoff decision).
• A patient with terminal disease asks for assistance in ending their own life.

Malpractice

• A patient receives wrong treatment/test: Inform the patient, even if no harm has been inflicted, and apologize.

Emotional support

• A patient complains that she feels “ugly” after a mastectomy.
  • Support the patient in identifying and breaking down the reasons why she feels this way.
  • Avoid comments that give false comfort (e.g., “You look good anyway”).
• A 6-year-old child experiences the death of a sibling and feels responsible.
  • Describe with simple and honest words what happened, avoiding euphemisms and clichés.
  • Offer reassurance, explaining to the child with clear and logical arguments that they cannot be responsible in any way.
  • Help the child to label feelings and fears, and normalize them.
  • Encourage healthy coping behaviors (e.g., making time for playing, creating a special way to remember their sibling).

Miscellaneous cases

• Angry patient (e.g., waiting at the office for a long time): Apologize, acknowledge anger, refrain from justifying or explaining the delay.
• A patient complains about the treatment received from another physician.
  • Suggest that the patient contacts that physician directly to speak about their concerns.
  • If the issue regards a member of your staff, let the patient know you will address the issue with the staff member personally.
• A patient requests an unnecessary intervention (e.g., diagnostic or therapeutic procedure, unnecessary medication).
  • Find out why the patient wants the intervention and address any underlying concerns.
  • Avoid performing unnecessary medical or surgical interventions.
  • Do not refuse to see the patient or refer the patient to another physician.
• A patient has poor adherence to or difficulty taking medications.
  • Identify the underlying causes of nonadherence.
  • Take a nonjudgmental stance and use motivational interviewing if possible.
  • Evaluate the patient's willingness to change.
  • Describe the treatment plan in easily understandable language, give written instructions, use the teach-back method, and involve close friends and relatives (with the permission of the patient).
  • Do not refer the patient to another physician.
• A pharmaceutical company offers a physician a sponsorship to advertise a new drug.
• A physician is impaired in the work environment (e.g., due to substance use).
• A patient shows attraction to a physician.
  • Romantic relationships between patients and physicians are never appropriate.
  • Ask specific, close-ended questions.
  • Use a chaperone if needed.
  • Consider transitioning care to another physician.
• A patient asks a medical student to disclose treatment, diagnostic, or prognostic information. [91]
  • Medical students usually lack the experience and knowledge to disclose complex diagnostic, treatment, or prognostic information.
  • Hence, they should ensure the following:
    • Act in the best interest of the patient at all times.
    • Maintain honesty (if the information is available, explain why disclosure has been postponed).
    • Inform the patient that complex treatment plans or diagnostic information will be disclosed by senior members of the team.
    • Disclosure should take place in an appropriate environment and at a suitable time to ensure that the patient's privacy and emotional needs are met.
• A patient needs medical therapy that is not covered by their insurance.
• Parents refuse to vaccinate their child. [37]
• Self-treatment and treatment of relatives [92][93]
• A patient requests that a physician intervenes in a conflict with one of their family members. [94]
  • Encourage the patient to voice their concern directly to the family member.
  • Avoid a triangulated relationship: A triangulated relationship occurs when two individuals that are in conflict both try to align with a third individual for support and/or mediation.
  • If both the family members are the physician's patients and one of the family members has difficulty voicing their concern to the other, the physician can:
    • Offer a space for communication between the two individuals during a family consult (family interview).
    • Refer the patients to a family therapist.
  • In the case of suspected abuse or neglect, the physician should intervene on the patient's behalf. (See elder abuse, child maltreatment, and domestic violence.)

References

Is it ethically correct to offer patient refusal of treatment?

What is the principle involved when the client is allowed to refuse treatment if he so decided?

What is the term for a patient who fails or refuses to cooperate with the recommendations of a healthcare professional?

Which of the following is an example of implied consent?