Posted by: notdeaddinosaur | September 25, 2012

The Ethics of Stupidity

Several folks have been kind enough to point out this story, and suggest that I may have an opinion on it:

[A woman from] Shrewsbury, Mass., claims that Dr. Helen Carter, a primary care physician at the UMass Memorial Medical Center in Worchester, refused to treat her because she is clinically obese…

It seems the good doctor has decided not to care for anyone (it is unclear if the prohibition applied to all patients or just to females) weighing over 200 lbs. Apparently there was a nearby specialty facility capable of caring for obese patients, so no one was being sent away with no resource to medical care.

There is nothing either illegal or unethical about this policy, according to the AMA and others. Much hullabaloo has ensued in the various comment trails, with many people stating that it should be (illegal. unethical, or both.) They are wrong. The only thing this physician has done is set her weight limit unreasonably low.

Here are the magic words: Scope of Practice. It means that doctors have not only the right but the ethical and legal responsibility to limit the care they provide based on their capabilities, their training and their experience, which together also translate to “comfort level”.

Lots of commenters ranted about “discrimination”. The problem is that one person’s “discrimination” is another’s scope of practice. Do gynecologists get blasted for refusing to care for 50% of the population? Why aren’t pediatricians condemned for transferring their patients out at 18 or 21 or 25 or whenever? What about Family Doctors who refuse to see kids under 11? (They’re just wusses, IMHO, but does anyone accuse them of being unethical?”)

What if I refer a diabetic whose blood sugars are persistently greater than 500. Am I discriminating against diabetics, or am I being a responsible clinician? What about someone whose sugars are over 300? 200? At some point, I’m just being lazy, but the point is that there are limits.

Look at the weight issue like this: re-write the whole story, except change the weight mentioned to 700 lbs.

I know I couldn’t take care of someone that big. My scale doesn’t go anywhere near that high (even with my special trick). My blood pressure cuffs are too small, as are my exam tables. My waiting room furniture is pretty sturdy, but I’d worry about collapse (with ensuing injury to the patient). If I were near enough to refer patients to a specialized bariatric site, I’m sure everyone would agree that it would be appropriate.

What about a patient weighing 500 lbs; same deal, pretty much. 400? Getting closer. 300? There are plenty of people who weigh that much without being clinically obese at all. Tall people; athletes. Definitely well within my scope of practice.

The question is NOT “where do we draw the line”, but rather admitting that drawing a line somewhere is logical, as well as ethical and legal.

The reason the AMA’s position is that,”…patients and doctors can “exercise freedom in choosing with whom to enter into a patient physician relationship…” is because just becoming a professional doesn’t mean you lose your autonomy. I know doctors who refuse to care for patients who smoke. (I would love to refuse to care for stupid people, but I’d probably starve.) Mark my words: you are going to see more and more doctors refusing to take care of people whose blood pressures, sugars, and other chronic diseases remain uncontrolled, in order to increase their “quality” scores (and presumably their income).

There are good and bad reasons for refusing to care for certain groups of patients. Weighing over 200 lbs is not a particularly compelling one, though plugging in some other number would be. Just don’t go confusing “stupid” with “unethical”. Dr. Helen Carter of Worcester is guilty merely of the former, though not the latter.

 


Responses

  1. This will become VERY common as pay for performance becomes more widespread.

  2. My problem is that the doc indicated that the “reason” was to avoid her staff getting hurt. There was no indication in the artlcle that the patient has a mobility impairment of any kind, let alone one that would require staff to lift her. If she were to collapse surely 911 would be called and paramedics would be responsible for moving her. A large BP cuff is not difficult to find nor prohibitively expensive, and I doubt her staff are in danger giving a 200 lb. patient an injection, taking their temp., etc.

    Clearly this doctor is not a good choice for this particular patient, but the “reason” given is insulting to the intelligence. Otherwise, if she wants to eliminate half the population as potential customers…

  3. 200 pounds seems arbitrarily low, but as you note the concept is sound. At some point, well above 200 pounds, morbidly obese patients need a specialist.

    Of course it’s Dr. Carter’s choice.

  4. I agree with you 100%. (Why do I feel a tad chilly?)

  5. I’ve always thought it was better to see someone who was busy. If you’re big seeing a doctor who sees a lot of big people would mean he/she would be attuned to your particular issues and you could well get more personal care.


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