Any threat to the celebrated individualism of American citizens is usually met with fierce debate — be the enemy mandatory health coverage or a ban on 64-ounce sugary soft drinks. What happens, then, when the results of these individual choices conflicts with the limitations of reality?
Obesity was categorized as a disease by the American Medical Association only one year ago but in many ways it defies such neat classification. In the AMA’s own statement on this new policy, the true target of the categorization was less the actual increasing body mass index of Americans than the diseases like heart disease and diabetes that frequently accompany it. The suggestion that a person’s “disease” of body size may require different treatment seems to blame the person for their “choices”, when in reality there are many causes of obesity including congenital endocrine disorders, physical disability and side effects of medication. In the absence of pathology, obesity is linked to socioeconomic disadvantage, which is hardly a voluntary circumstance. Naturally, the denial of care to patients who don’t feel they have done anything wrong looks and feels like discrimination.
How does this play out in the clinic? Regardless of the new policy, many patients only see their physicians for a fifteen-minute checkup once per year — hardly enough time for effective counseling. These patients have a significant predisposition toward multiple chronic diseases, and additional complications may arise due to excess weight itself: intubations are harder to perform, musculoskeletal problems are common due to different biomechanics, the pharmacokinetics of drugs are altered, and equipment may be the wrong size. Still, the refusal to treat patients is rarely done. The AMA supports the ethical freedom of physicians to choose with whom to enter into a doctor-patient relationship and physicians in the US are almost always permitted to withhold non-emergency care from patients however, they typically only do so when faced with “controversial circumstances, such as the decision to perform an abortion or to withhold or withdraw life-sustaining treatment.”
Dr. Helen Carter of Worcester, Massachusetts is one of these rare examples of how physicians have approached the treatment of obese patients. In 2012 the internist’s medical office began refusing to treat new patients over 200 pounds after one physician in the practice sustained a serious neck injury helping an obese person on an exam table. Dr. Carter implemented the policy, claiming that she would be “paying the cost of other people’s choices,” by adapting her practice with new equipment to care for heavier people. She prioritizes the principle of justice over that of beneficence; She is declining to provide care to a specific population so that her resources are more available for the treatment of her other patients. Dr. Carter adds that, “the problem with obesity is it has become socially acceptable.”
So how discriminatory is the practice’s new policy, and others like it? A likely factor to the rareness of refusing treatment in the US is the difficulty in creating a hard-and-fast rule determining who is treatable and who is not. Dr. Carter’s willingness to do exactly that is what makes her policy so striking (and ridiculous, for making the weight limit so low). Does an obese person have to be over 200 or 600 pounds to be sent to a different clinic? Does the smoker have to have a two- or 20-pack-year habit to be denied care? Most physicians would be hesitant to draw these kinds of lines in the sand after all, they presumably want to help people and it may not be worth the savings in cost of new equipment to be considered discriminatory. In the past, selectivity has been simply bad for patients. When surgical “report cards” and other measures of outcomes were implemented in the US, surgeons were found to be more likely to cherry-pick healthy patients on whom to operate since they were less likely to suffer complications. Naturally, this practice of selection bias left some high-risk surgery candidates without the procedures they need. Would a similar effect occur in the population of patients turned away from a general practitioner’s office like Dr. Carter’s? It isn’t hard to imagine that the delay of primary care to the entire population of obese patients would result in as many missed diagnoses and poorer care.
The power of a physician to limit the scope of their practice in ways they see fit is an important right. The scope of many physicians’ practice is already inherently limited by specialization in a given area and this is important for patients’ well-being. A dermatologist may not be the ideal provider of treatment for a gunshot wound but the decision to specialize in dermatology is beneficial for patients who need dermatologic care. Similarly, an anesthesiologist may decline to perform a pediatric case so that another anesthesiologist with expertise in that area can provide more tailored care. If a physician knows that he or she lacks sufficient resources or experience to provide a person with the best care possible and there is an alternative available, the patient should be directed to the more ideal provider.
Clearly, there should be conditions to a physician’s ethical right to turn away obese patients: firstly, the existence of a better alternative physician and secondly, a decision made on the basis of helping the patient find suitable care (as opposed to simple disagreement with their “lifestyle”). The first condition may become easier to accomplish as managed care and health maintenance organizations become virtually ubiquitous in the United States; finding and referring a patient to the ideal specialist should become more seamless. The second condition requires asking what kind of medical office or practitioner is “suitable” for an obese patient and this makes it difficult to assess a case like that of Dr. Carter because her standard for “acceptable weight” was so stringent. It seems that the practice’s goal is to preempt any patient care situation where weight could potentially be an issue, rather than determining upon meeting a patient whether his or her weight will be. While equipment, safety and financial resources are understandable concerns, seeking to avoid ever having to think about obese patients is not one; her frustration did not arise from a lack of training but rather from a personal objection.
Frustration with ineffective obesity counseling reflects the larger general issue in medicine of noncompliant patients (assuming the patient’s obesity is not secondary to some other pathology). It is estimated that only half of the billions of prescriptions written each year in the United States are properly taken and 33-69% of hospitalizations related to medication are due to inadequate compliance. It isn’t difficult to imagine that a long-term goal like a lower body weight would be hard to attain, if even filling a prescription is infrequently done. Indeed, if physicians were to deny care to noncompliant patients on this basis, these physicians would quickly run out of people to treat (and money).
More importantly, turning away a noncompliant patient establishes a paradoxical and dangerous situation in which the patients who may need the most medical attention have a more difficult time finding it. This is quite evident when considering patients with addiction. If physicians declined these patients because they are noncompliant or frustrating to treat, recovery might be near impossible. However, addiction treatment differs from obesity treatment in that it is not uncommon for some physicians to specialize in addiction. Geriatric patients, for example, have health care needs that differ from the general population to some degree, so some physicians specialize in geriatrics. This helps the field of medicine adapt to better serve the population and such an effect might improve obese patients’ health care if implemented thereby preventing physicians like Dr. Carter from having to turn patients away at all.
Treating patients differently than others can imply blame or fault however, physicians can help mediate this uncomfortable relationship between American society and obesity by making it clear that it is done first and foremost for the benefit of the patient. The right of a physician to limit his or her scope of practice is a critically important one but doing so should only be considered ethical when the patient denied has a recourse and when it is in the patient’s best interest. The responsibility of physicians to their obese patients and all patients, is simply to provide the best care possible given their knowledge and ability and to do so with compassion.