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2.5 FAILURE TO COOPERATE IN THE THERAPEUTIC RELATIONSHIP

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A therapeutic relationship is constituted by two parties who cooperate in the effort to achieve the goals of medicine, that is, curing and caring. Both parties can withdraw, partially or totally, willingly or unwillingly, from this cooperative effort. Patients may give consent to a treatment recommendation but fail to follow the recommended treatment, while still wishing to continue the therapeutic relationship. This situation was once commonly called “non-compliance,” although that term is seldom used today because of its paternalistic overtones. The problem, whatever it is called, can create persistent ethical dilemmas for all involved. Also, there are occasions in which physicians and other health professionals are unwilling to provide some forms of care. This raises the ethical problem of conscientious objection.

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2.5.1 Question Six—Is the Patient Unable or Unwilling to Cooperate With Medical Treatment? If so, Why?

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Physicians have the responsibility to recommend to patients a course of treatment or behavior that would, in the physician’s best judgment, help the patient. Patients have the right to be informed of the benefits and risks associated with these recommendations and to accept them or refuse them. These rights and responsibilities are in principle quite clear. However, patients may fail to act on their physician’s recommendations, yet continue to seek the care of the physician. In place of the terms “non-compliance” or “non-adherence,” we use the expression “failure to cooperate with medical recommendations.” The problem posed to physicians is how to perform their ethical responsibilities to patients who ask for help but for some reason do not, or cannot take the advice or consent to the treatment that is offered.

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2.5.2 Failure to Cooperate With Medical Recommendations

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A patient may not cooperate with recommended treatment for many reasons. The following cases represent two examples of this very complex problem.

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CASE I. Ms. Cope is a 42-year-old woman with insulin-dependent diabetes who, despite good compliance with an insulin and dietary regimen, experienced frequent episodes of ketoacidosis and hypoglycemia which necessitated repeated hospitalizations and emergency room visits. For the past few years, her diabetes has been better controlled. She was been actively involved in her diabetic program, scrupulous about eating habits, and maintained ideal body weight. Twenty-one years after the onset of diabetes, she appears to have no functional impairment from her disease.

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Three years ago, Ms. Cope went through a stormy divorce and lost an executive position. She has gained 60 lbs. and has become negligent about her insulin medication. She has also started to drink alcohol heavily. During these years, she has required frequent admissions to the hospital for diabetic complications, including (1) ketoacidosis, (2) traumatic and poorly healing foot ulcers, and (3) alcohol-related problems. While in the hospital, her diabetes is easier to manage but even in the hospital, she is frequently found in the cafeteria eating excessively. On two admissions, blood alcohol levels in excess of 200 mg/dL were detected. Soon after discharge from the hospital, her diabetic control lapses.

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Her physician is frustrated. He blames the recurring medical problems on the patient’s unwillingness to participate actively in her own care by losing weight, taking insulin regularly, and giving up alcohol. The patient promises to change her lifestyle, but on discharge from the hospital, she relapses almost immediately. The physician urges her to seek psychiatric consultation. She agrees. The psychiatrist suggests a behavior modification program, which proves unsuccessful.

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After 10 years of working closely with this patient, the physician considers withdrawing from the therapeutic relationship, because he senses he is no longer able to help the patient. “Why keep this up?” he says to the patient. “It’s useless. Whatever I do, you undo.” The patient resists this suggestion. She complains that the physician is abandoning her. Does persistent failure to comply with medical advice justify an ethical decision to withdraw from a case?

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COMMENT. The following comments are relevant to this question:

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  1. Patients such as Ms. Cope are very frustrating to those who attempt to care for them. Occasionally, the physician will accuse the patient (in words or in attitude) of being irresponsible. The patient engages constantly and apparently willfully in behavior that poses a serious risk to health and even to life. Such patients place great strain on the doctor-patient relationship

  2. The accusation of irresponsibility can be an example of the ethical fallacy of “blaming the victim”; the actual fault may lie with a more powerful party who finds a way to place the blame for his own failure on the ones who suffer its effects. The apparent irresponsibility of patients may result from the failure of a physician to educate, support, and convey a personal concern and interest in the patient. Even more, persons may be rendered incapable of caring responsibly for themselves by the way their physician deals with them. An excessive paternalism may stifle responsibility. Although Ms. Cope’s physician did not have these faults and had made solicitous efforts to support Ms. Cope, this problem may lie behind many cases of a patient’s failure to cooperate.

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RECOMMENDATIONS.

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  1. It is important to determine whether and to what extent the patient is acting voluntarily or involuntarily. Much uncooperative behavior is voluntary. Patients either choose to ignore the regimen in favor of other behaviors they value more than health (a goal that, in an asymptomatic disease, may not seem very urgent or immediate) or fail to cooperate because of such factors as irregular routine, complicated regimen, habitual forgetfulness, or poor explanation by the physician. Some noncompliance is nonvoluntary, arising from profound emotional disturbance or psychological disabilities and ambivalence.

  2. If the physician judges that noncooperation is voluntary, reasonable efforts at rational persuasion should be undertaken. If these fail, it is ethically permissible for the physician to adjust therapeutic goals and do the best in the circumstances. It is also ethically permissible to withdraw from the case, after advising the patient how to obtain care from other sources. This should be done in accord with the ethical and legal standards noted in the following section.

  3. If noncooperation is the result of a psychological or physical disorder, the physician has a strong ethical obligation to remain with the patient, adjusting treatment plans to the undesirable situation. Professional assistance in treating the disorder should be sought. The physician will experience great frustration, but the frustration is not, in itself, sufficient to justify leaving the patient.

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CASE II. Ms. Cope is admitted for inpatient treatment of obesity with a protein-sparing modified fasting regimen. She was found repeatedly in the cafeteria cheating on the diet. Clinicians made reasonable efforts to persuade her to change her behavior. A decision was made to discharge her, against which she protested vigorously.

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RECOMMENDATION. It is ethically permissible for the physician to terminate therapeutic efforts and to discharge the patient from the hospital. The goals of therapy are unachievable because of the patient’s failure to participate in the program. This decision may be the culmination of a long history of failure to cooperate that leads to the physician’s decision to withdraw from the care of Ms. Cope.

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Failure to cooperate in a medical regimen is a most complex problem that may be rooted in psychological, social, or economic features of the patient’s life, as well as in the difficulties of understanding and navigating the medical system. It is incumbent on physicians to understand the deep roots of this problem.

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2.5.3 The Disruptive Patient

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On occasion, persons who are under care in a health care facility may cause serious disruption and even endanger other patients. At the same time, they may desire to continue treatment. Physicians who encounter such challenging patients may be concerned that discharging them because of the danger posed to others or the disruptions caused, may cause serious harm, even death, for the patient.

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CASE. Mr. R.A., an intravenous drug addict, is admitted for the third time in three years with a diagnosis of infective endocarditis. Three years before, he required mitral valve replacement for Pseudomonas endocarditis, and one year ago, he required replacement of the prosthetic valve after he developed Staphylococcus aureus endocarditis. He now is admitted again with S aureus endocarditis of the prosthetic valve.

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After one week of antibiotic therapy, he continues to have positive blood culture results. One cardiac surgeon refuses to operate, saying that the patient is a recidivist and that correcting his drug addiction is futile. Another surgeon agrees to operate. R.A. consents to open heart surgery to replace again the infected prosthetic mitral valve. For 10 days postoperatively, he is cooperative with his management and antibiotic treatment. On this treatment he becomes afebrile and blood culture data are negative. Plans are in place for discharge, with venous access for antibiotics.

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He then begins to behave erratically. He leaves his room and stays away for hours, often missing his medications. On several occasions, a urine-screening test demonstrates the presence of opiates and quinine, revealing that he is using illicit narcotics even while being treated for infective endocarditis. Two repeat blood culture tests now grow S aureus. On two separate occasions, he verbally abuses two nurses who reprimand him for being away from his room. Several patients on the unit complain that he threatened them. Nurses suspect that he is also dealing drugs within the hospital. This information becomes known to the patient’s physician. Despite the fact that the patient’s infective endocarditis has not been treated optimally, the physician discharges him from the hospital immediately.

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COMMENT. Considerations leading to an ethical justification of this decision are as follows:

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  1. The patient’s use of intravenous street drugs at the same time that his physicians were attempting to eradicate his infective endocarditis indicated that the likelihood of medical success in this case, both short term and long term, was unlikely. Physicians are not obliged to treat people who persist in actions that run directly counter to the goals of treatment.

  2. The patient wanted to be treated and, at the same time, continued his abusive behavior. The physicians are obliged to determine that the patient has the mental capacity to make such choices and that he was not suffering from a metabolic encephalopathy (see Section 2.2.3).

  3. Providers should try to understand the complex causes of his behavior and motivations. They should avoid “blaming the victim.” Serious efforts should be made to counsel, to negotiate, and to develop “contracts” that make clear to him the consequences of his behavior. Early and repeated warnings should be issued. One identified provider should be responsible for dealing with this patient.

  4. In addition to his uncooperative behavior which is harmful to himself, he disrupts the functioning of the hospital and impedes the care of other patients. This contextual feature provides an additional argument in favor of his discharge. The ethical basis of this argument is fairness: his behavior deprives other patients of rightful attention.

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RECOMMENDATION. Clinicians should recognize that this patient’s primary medical problem is not endocarditis, serious though that condition is. As the first surgeon noted, it is drug addiction. The focus of his treatment should shift to treatment for that problem. The management of addiction requires long-term outpatient care and support. Nevertheless, he is at risk of dying in the short term from another episode of infective endocarditis. In our opinion, he should be discharged with an indwelling venous line and with home nursing service to administer antibiotics. This is not optimal care, but it would provide reasonable care to this patient while protecting the interests of others. If he proves intractable, then it can be argued that efforts to manage his endocarditis by surgical means will not be effective and the patient may be discharged.

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2.5.4 Signing out Against Medical Advice

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Mr. R.A. might simply walk out of the hospital, leaving before physicians judge his treatment adequate. When patients choose to discharge themselves in this manner, most hospitals request them to sign a statement confirming that they are leaving against medical advice (AMA). The patients, however, cannot be forced to sign the statement; they have the right to leave at will. The document merely provides legal evidence that the patient’s departure was voluntary and that the patient has been warned about the risks of leaving.

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2.5.5 Conscientious Objection

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The preferences of patients have significant moral authority and must be considered in every treatment decision. Even the preferences of decisionally incapacitated patients are relevant to the decisions of those who must act in their behalf. However, the authority of patient’s preferences is not unlimited. The ethical obligations of physicians are defined not only by the wishes of their patient but also by the goals of medicine. Physicians have no obligation to perform actions beyond or contradictory to the goals of medicine, even when requested to do so by patients. Patients have no right to demand that physicians provide medical care that is contraindicated, such as unnecessary surgery or medically inappropriate drug regimens. Patients may not demand that physicians do anything illegal. For example, physicians must not provide certification of a disability that the patient does not have or fail to report at a patient’s request a legally reportable communicable disease. Finally, physicians may refuse to accede to a patient’s wishes when they believe that doing so will make them complicit in something they believe is immoral.

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Traditionally, medical ethics has required physicians to abstain from moral judgments about their patients in regard to medical care. For example: (1) an ED physician is expected to provide competent care to both the wounded assailant of an elderly person and to the assaulted party; and (2) a physician should treat, without censure, venereal disease contracted in what the physician considers an immoral liaison. However, despite this professional neutrality, physicians and nurses have their own personal moral values. On occasion, they may be asked not merely to tolerate what they consider immorality but to participate in what they consider an immoral action desired by the patient. For example: (1) A male patient requests a physician who considers transsexuality morally wrong to prescribe female estrogens to promote secondary female characteristics; (2) a Catholic nurse is asked to participate in an abortion. Refusal to participate is described as conscientious objection which means a judgment formed on the basis of sincerely held moral values that participation in some particular action would be violating one’s own moral standards. Usually laws permitting abortion and laws permitting physician-assisted dying contain explicit exemptions for conscientious objection by physicians and nurses.

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Providers may invoke conscientious objection in other situations that may be not only controversial but also not legally justified. For example, a pharmacist refuses to fill a valid prescription for “morning after pill.” A physician may conscientiously judge that a particular law is unethical. For example, a physician who is treating patients with AIDS is convinced that smoking marijuana relieves the pain and nausea of advanced illness, but state law prohibits prescription of medical marijuana.

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Physicians and nurses may refuse to cooperate in actions they judge immoral on grounds of conscience. The formation of a conscientious objection is a serious moral act. It calls for a thoughtful reflection on the moral grounds of the objection and on the consequences of holding such a position. It implies that the conscientious objector is willing to accept any legal liability that follows from violation of law. It is important for a conscientious objector to make public his or her objection. Conscientious objection must not merely be prejudice or distaste. Finally, providers who have conscientious objection to some procedures may refer the patient to a more cooperative provider. Even this, however, is controversial. Some object that a referring provider is complicit in the immoral action; it is best, they say, to simply refuse. Others argue that a referral leaves the blame for any immoral procedure on those who engage in it. Regardless of this controversy, a refusal to treat that would cause serious harm would seem morally unacceptable. Institutions should establish policies that reflect state laws and moral guidance on conscientious objection.

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Curlin  FA, Lawrence  RE, Chin  MH, Lantos  JD. Religion, conscience, and controversial clinical practices. New Engl J Med. 2007;356:593–600.
CrossRef  [PubMed: 17287479]

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2.5.6 Withdrawing From the Case and Abandonment of the Patient

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At times, such as the case of Ms. Cope (see Section 2.5.2), the physician may serve the patient best by deciding to dissolve the physician-patient relationship. The physician’s principal goal is to help patients in the care of their health. If this proves impossible, the physician may best demonstrate ethical responsibility by withdrawing from the case.

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Physicians who terminate a relationship with a patient sometimes wonder whether they can be charged with abandonment. Abandonment, in the legal sense, means that a physician, without giving timely notice, ceases to provide care for a patient who is still in need of medical attention or when the physician is dilatory and careless (eg, failure to see the patient at a time of urgent need or failure to judge the patient’s condition serious enough to warrant attention). A charge of abandonment can usually be countered by showing that the patient did receive warning in sufficient time to arrange for medical care. The physician is not legally obliged to arrange for further care from another physician, although there is a legal obligation to provide full medical records to the new attending physician. If the physician does intend to maintain the relationship with the patient but will be unavailable for a time, there is a legal obligation to arrange for coverage by another physician. Failure to do so can be construed as abandonment.

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Thus, a physician may withdraw from the care of a patient without legal risk. The decision to do so should meet ethical as well as legal standards. Physicians inherit an ethical tradition that requires them to undertake difficult tasks and even risks for the care of persons in need of medical attention. Inconvenience, provocation, or dislike is not a sufficient reason to exempt a physician from that duty. That obligation is, of course, limited by several conditions. If the patient absorbs excessive time and energy, drawing the physician away from other patients, if the patient is acting in ways to frustrate the attainable medical goals, or if the patient is endangering others by overt action, the ethical obligation to continue to care would be diminished. These conditions appear to be verified in the case of Mr. R.A. Finally, a physician may decline to provide nonbeneficial treatments or treatments.

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2.5.7 Complementary/Alternative Medicine

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Some persons seek health care from alternative providers outside or in addition to conventional scientific medicine. It is estimated that one out of three adult Americans make a total of 425 million visits to alternative providers—more than are made to primary care practitioners. These providers include naturopaths, homeopaths, chiropractors, acupuncturists, and practitioners of traditional Chinese, Indian, and Native American medicine. In several states, homeopathic and naturopathic doctors are licensed as medical practitioners. Methods include spiritual healing, physical manipulation, special diets, imaging, relaxation techniques, massage, and vitamin therapy, and attention is paid to nutrition, exercise, and stress reduction. These methods are described as alternative or complementary medicine. Integrative medicine designates programs that attempt to find and utilize the benefits of both alternative and orthodox medicine. Some prominent medical institutions have established programs in integrative medicine.

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Adams  KE, Cohen  MH, Eisenberg  D, Jonsen  AR. Ethical considerations of complementary and alternative medical therapies in conventional medical settings. Ann Intern Med. 2002;137:660–664.
CrossRef  [PubMed: 12379066]
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Cohen  MH. Alternative and complementary medicine. In: Singer  PA, Viens  AM, eds. The Cambridge Textbook of Bioethics. New York, NY: Cambridge University Press; 2008: chap 65.

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CASE. Mr. DS, a 54-year-old man, has been under the care of a family physician for increasingly severe anxiety and depression. The physician has treated him with fluoxetine (Prozac) initially and then with paroxetine (Paxil). On a routine visit, the patient complains of shivering, sweating, and feelings of agitation. The physician questions the patient, and the patient reluctantly admits that he has been seeing a “natural healer” who recently encouraged the patient to take St. John’s wort (Hypericum perforatum) as treatment for his depression. The family physician suspects that the patient may be experiencing serotonin syndrome and admits him to the hospital for observation.

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COMMENT. Many persons who visit alternative practitioners are also under the care of regular practitioners, using unconventional therapies as adjuncts rather than replacements of conventional therapy. Many of these patients do not inform their regular physician about their use of alternative treatment. In the case of DS, the combination of Paxil and St. John’s wort can cause high levels of serotonin, and this can result in a life-threatening problem known as serotonin syndrome. Persons are often motivated to seek alternative treatments because they are less arduous and less costly than conventional treatments, or because patients are frustrated with the failure of conventional treatment to assuage problems such as chronic back pain, headache, insomnia, anxiety, and depression. Most conventional practitioners know little about alternative medicine, and many commonly disdain it and disparage its claims.

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Boyer  W, Shannon  M. The serotonin syndrome. N Engl J Med. 2005;352:1112–1120.
CrossRef  [PubMed: 15784664]
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Clark  PA. The ethics of alternative medicine therapies. J Public Health Policy. 2000;21:447–455.
CrossRef  [PubMed: 11214376]

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RECOMMENDATIONS.

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  1. Regular physicians should encourage their patients to reveal their use of alternative medications. They should refrain from disparaging remarks that can inhibit patients from speaking about what they fear will lead to anger or ridicule on the physician’s part.

  2. Conventional physicians should try to attain a better understanding of the healing systems to which patients have recourse and to appreciate their beneficial features. Persons often take substances that are advertised or promoted on Web sites, without supervision of either alternative or regular physicians. This unsupervised medication may have adverse effects. For example, licorice, an herb used in many supplements promoted for relief of fatigue can lower serum potassium significantly; many supplements, such as fish oils, may affect coagulation. When regular practitioners see these effects, they may neither know that their patients are using these substances, nor understand their nature and risks. Patients should be asked whether they are using alternative medications. Consultation with an established complementary and alternative medicine (CAM) practitioner or program may be advisable. Reliable information about herbal medications can be found in the Botanical Safety Handbook (CRC Press) or at HerbMed, www.herbmed.org. Also, National Institutes of Health (NIH) now has the National Center for Complementary and Alternative Medicine, nccam.nih.gov.

  3. When patients are using alternative therapies for serious conditions to the neglect of demonstrated efficacious therapies, or when they are using therapies that have toxic effects, physicians should carefully explain the consequences of such a course. A clumsy or uninformed approach may confirm patients in the use of inadvisable therapy rather than convert them to more appropriate ones.

  4. In serious conditions, where the use of alternative medicine may impede cure or be dangerous, the physician should ask the patient’s permission to contact the alternative provider, explain the situation, and negotiate a program that will be acceptable to the patient and conformable to the ethics of both providers.

  5. Hospitals should develop policies that acknowledge the prevalence of alternative therapies and establish guidelines for acceptable collaboration between regular physicians and providers of alternative treatments.

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