Can a Doctor Deny Medical Care?

Some time ago, a man came to see me requesting a colonoscopy.  His last colon exam was done about 5 years ago.  He is well into his 80’s and has several significant chronic medical conditions.  He wanted reassurance that he did not have colon cancer.  Who wouldn’t want to be reassured of this?  After questioning him closely and reviewing the medical data I advised him that I was not suspicious that he was harboring a colon malignancy.  The patient, however, was not mollified.  As the professional, I advised that in my judgement the risks of the procedure exceeded the potential benefits.  Indeed, this is the risk calculation that physicians utilize daily when advising patients on diagnostic and therapeutic options.

While I didn’t categorically refuse to perform the procedure, I was reluctant to proceed.  I asked the patient’s internist, who knew the patient well, to delve into this issue further with him.  As I did not hear back from the doctor or the patient, I cannot offer readers an update.

I made clear to the patient that while I was sanguine regarding the health of his colon, of course I could not guarantee this.  This is not how medicine works.  As I have expressed from time to time, there are no guarantees in medicine or in life.  We can never achieve 100% certainty even after subjecting patients to testing.  It is well documented, for example, that even an expertly performed colonoscopy can miss significant lesions including cancer.

Physicians and patients may have similar or different risk tolerances.  A patient, for example, may desire additional testing to increase the odds that nothing of significance has been missed.  Is 90% certainty sufficient?  95%?  Of course, the threshold would be different for a benign condition as opposed to a serious one.  There is not correct answer here and these issues need to be teased out in the office.

In the era of patient autonomy, the patient makes the call.  Accordingly, even if the risks exceed the benefits, doesn’t the patient have the right to make a risky choice to achieve greater certainty?  But are we physicians obligated to acquiesce to such requests?  Could a patient demand surgery against the advice of a surgeon because the patient is willing to accept long odds of success?

Should a patient be allowed to demand surgery?

In an analogy, if a client wants to make a financial investment that his advisor feels is very risky, shouldn’t the advisor execute the request assuming that the client is of sound mind?  The investor may have rationale reasons for proceeding despite his advisor’s dissenting view.

In medicine, unlike in finance, I don’t think patients should expect that doctors will do anything we are asked to do.  Medical tests have risks.  They can cause all manner of harm and injury.  Just like our patients may refuse medical care, we have a right to refuse to act if we believe that such action poses excessive risks and conflicts with our ethical standards.  These can be delicate conversations.  If a physician declines a patient’s request for a colonoscopy or a heart catheterization or an operation, then this doctor should refer the patient to a colleague for another opinion.