On Patient Abandonment
American Occupational Therapy Association
Ethics Commission
Advisory Opinion on Patient Abandonment
Summary:
The duty to treat, patient abandonment, and occupational therapy are examined in this advisory opinion. The occupational therapy practitioner has a variety of resources available to enable their adherence to high ethical standards. The advisory opinion encourages practitioners to abide with rather than abandon the recipient of services.
"Abandonment" in the Health Care Setting
In the New Expanded Webster's Dictionary, abandonment is defined as: "A total desertion." (Patterson, 1991, p. 5) Taber's Cyclopedic Medical Dictionary clarifies what abandonment means in the health care setting: "The abandoning, without adequate warning, of a patient needing further medical care by the person responsible for that care." (Thomas, 1993, p. 1)
One should note that according to this second definition, a health care professional can indeed "abandon" a patient, as long as some notice has been given. Tangential to withdrawing from a case in which treatment has already begun is the refusal to initiate treatment, which many patients also take as an act of abandonment. This "right" (as it sometimes called) of health care professionals to withdraw from the treatment of a patient, or to refuse to initiate treatment, is supported by the American Medical Association's Principles of Medical Ethics, Principle VI: "A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with who to associate, and the environment in which to provide medical services." (AMA, p. 101) Similarly, the Comprehensive Accreditation Manual for Hospitals (JCAHO, Jan. 1998, p. HR-21) calls for the development of policies and procedures within health care facilities governing: "How staff may request to be excused from participating in an aspect of patient care on grounds of conflicting cultural values, ethics, or religious beliefs; …."
Belief in this "right" of health care professionals to refuse to treat can be found throughout the health care system in this country, because it flows out of the strong value Americans place on freedom of choice. As Albert R. Jonsen explains:
There has long been, in the United States, a reluctance to force one person to provide services to another against his or her will. … the right to refuse to care for a particular patient, either by not accepting that person as a patient or by discharging oneself from responsibility in a recognized way, is deeply embedded in the ethos of American medicine. (Jonsen, 1995, p. 100)
The issue of patient abandonment vs. health care professional's rights is one of several problems that contribute to the growing tension between patients and medical personnel. Finding and maintaining a balance between patient needs and the personal rights of those involved with health care delivery on this issue of abandonment would go far towards easing such tensions as we move into the next millennium.
Clarifying "Patient Abandonment"
We must recognize that there are legitimate reasons across all fields of health care to cease providing treatment to a patient. Some of these are clear-cut. First, when treatment needs exceed the ability and expertise of a health care professional, the patient is best served by having care transferred to a more qualified practitioner. Since the goal of health care is the well being of the patient, withdrawing from a case when one's skill can no longer be of benefit is justified, even though claims of abandonment may be raised by the patient. However, the manner in which one presents the need for a transfer of care, and the degree to which the patient is made aware of this need and involved in the choice of a new practitioner, are important factors in lessening the patient's perception of abandonment.
Second, it is commonly agreed that a health care practitioner may withdraw from the care of a patient who acts inappropriately within the health care setting. The most common situation discussed is when a patient becomes violent or acts in ways that endanger the practitioner, other patients, or staff. However, this would also include inappropriate sexual advances from a patient (or possibly from a patient's guardian, spouse, parent, etc.). In such cases, a practitioner may, if necessary, withdraw from the treatment of the patient without abandoning the patient, as the health care relationship has already been severed and the bond of trust damaged.
A third area, but one, which involves more difficulty, arises from issues regarding the cultural and religious values of health care practitioners. As noted in the Comprehensive Accreditation Manual for Hospitals – Refreshed Core (JCAHO, Jan., 1998, p. HR-21), in the delivery of health care there should be respect for a health care practitioner's, "… cultural values, ethics, and religious beliefs and the impact these may have on patient care". The Manual emphasizes that to respect all staff members, a health care institution (or practice) should establish policies for how staff members can make requests to discontinue care for ethical, religious, and cultural reasons, as well as policies for ensuring that patient care will not be negatively affected. It is further noted that addressing such issues in advance, even at the time of hiring or contracting, will be the most helpful for maintaining an appropriate level of patient care.
What makes these issues difficult is the subjective nature of "personal values." Who is to say what represents a cultural value? What if one's culture is in the minority -- do minority values still have weight? Religious values might also be difficult to determine, since not all members of the same religion hold the same values. Should those making the decisions recognize only mainstream values of the staff member's religion? And of course, ethical values flow from the individual's own conscience. How should a manager or a supervisor regard a staff member's ethical claims? Should all expressed values carry the same weight, simply because someone claims they are important? The Manual goes on to note that if an appropriate (in the judgment of the manager or supervisor) request has been made, accommodations should be made where possible and cites the following "Examples of Implementation" to support Standard HR.6.
- There will be an understanding that if events prevent the accommodation at a specific point because of an emergency situation, the employee will be expected to perform assigned duties so he or she does not negatively affect the delivery of care or services.
- If an employee does not agree to render appropriate care or services in an emergency situation because of personal beliefs, the employee will be placed on a leave of absence from his or her current position and the incident will be reviewed. (JCAHO, Jan. 1998, p. HR-21)
Such cases will surely be difficult for all involved, especially if they have not been addressed prior to the emergent situation. The issue here is further complicated by the fact that even though health care is becoming more diverse, when we work with each other we are not always aware of each other's diverse beliefs, nor are we always open and understanding about such differences. Supervisors and employers will need to become more aware of their staff's values, while staff will need to continue to keep patient care at the focus of their work during times of personal conflict.
Beyond the above reasons for discontinuing patient care, disagreement begins to arise. What about refusing to treat a non-compliant patient? What if that patient is extremely non-compliant vs. occasionally non-compliant? In another vein, what about the patient who does not pay her or his bills? Is refusing to treat such a patient justifiable? What if the patient is unable to pay the bills? Would this make a difference? Or, one might consider an especially demanding patient. If a patient takes time away from the care of others, and continually calls the practitioner beyond normal care hours, is withdrawal from the care of such a patient acceptable? Yet another problematic case might involve a patient whose appearance or manners disgusted a practitioner. If a practitioner is so put off by a patient that it impedes her or his ability to be an effective therapist, would withdrawing from the case be an act of abandonment or patient benefit? Finally, perhaps the most addressed cases involve persons with AIDS. Does the fear of contagion validate withdrawal from treating such a patient? Across the literature, there is little agreement as to what constitutes abandonment in such situations. Legal cases have not added much clarity. (Southwick, 1998, p. 37-41)
The Duty to Treat
Although there is disagreement about the issue of abandonment and the duty of health care professionals to treat patients, even in the face of personal inconvenience or risk, some helpful insights can be gained from the thought of Edmund D. Pellegrino. In his article, "Altruism, Self-Interest, and Medical Ethics," Pellegrino addresses the particular case of physicians and the treatment of persons with AIDS. To begin, the author questions the notion that, "medicine is an occupation like any other, and the physician has the same 'rights' as the businessman or the craftsman" (Pellegrino, 1991 p. 114) As a counter to this notion, Pellegrino draws out three things specific to the nature of medicine which he argues establish a duty of physicians to treat the sick, even in the face of personal risk. Pellegrino first points out the uniqueness of the medical relationship, in that it involves a vulnerable and dependent person who is at risk of exploitation who must trust another to be restored to health. As Pellegrino explains: "physicians invite that trust when offering to put knowledge at the service of the sick. A medical need in itself constitutes a moral claim on those equipped to help." Next, the author points out that, in short, medical education is a privilege. Societies make special allowances for people to study medicine for the good of the society, thereby establishing a covenant with future health care professionals. Based on this, Pellegrino concludes: "The physician's knowledge, therefore, is not individually owned and ought not be used primarily for personal gain, prestige, or power. Rather, the profession holds this knowledge in trust for the good of the sick." Finally, Pellegrino points to the oath that physicians take before practicing medicine: "That oath – whichever one is taken – is a public promise that the new physician understands the gravity of this calling and promises to be competent and to use that competence in the interests of the sick." Although the debate continues, several have asserted that Pellegrino has made a strong case for the duty to treat. (Arras, 1991, p. 115-121; Jonsen, 1995, p. 97-106) And although Pellegrino's comments are directed towards physicians, his reasoning cuts across all fields of medical practice.
The Duty to Treat, Patient Abandonment, and Occupational Therapy
The three points presented by Pellegrino above have direct bearing on the profession of occupational therapy. Occupational therapists recognize the vulnerability of the people who seek their services, and are aware of the trust that is required in the healing relationship. This is exhibited first in the Core Values and Attitudes of Occupational Therapy Practice. Even though the recipient of treatment depends upon the occupational therapist, the core value of equality, "requires that all individuals be perceived as having the same fundamental human rights and opportunities." (AOTA, 1993, p. 1085) The core value of dignity, "emphasizes the importance of valuing the inherent worth and uniqueness of each person. This value is demonstrated by an attitude of empathy and respect for self and others" (AOTA, 1993, p. 1086). The need for respecting the vulnerability of patients and building trust is also expressed in the Occupational Therapy Code of Ethics (2000). Principle 1 states, "Occupational therapy personnel shall demonstrate a concern for the well-being of the recipients of their services" (AOTA, 2000, in press). Principle 2 adds that, "Occupational therapy personnel shall take all reasonable precautions to avoid imposing or inflicting harm upon the recipient of services or to his/her property." Item A under Principle 2 also explicitly states that, "Occupational therapy personnel shall maintain relationships that do not exploit the recipient of services sexually, physically, emotionally, financially, socially or in any other manner." Principle 3 further demonstrates the concern of occupational therapists for building trust between practitioners and the persons in their care: "Occupational therapy personnel shall respect the recipient and/or their surrogate(s) as well as the recipient's rights." Under this principle the importance of collaborating with, gaining informed consent from, and respecting the confidentiality of recipients is recognized.
As to the second point raised by Pellegrino, occupational therapists do indeed recognize the importance of their training and education. This is emphasized in Principle 4 of the Occupational Therapy Code of Ethics (2000): "Occupational therapy personnel shall achieve and continually maintain high standards of competence." (AOTA, 2000, in press) The impact of this principle goes beyond just receiving specialized training. Occupational therapists seek to maintain, "competence by participating in professional development and educational activities." This fourth principle also directs occupational therapists to, "protect service recipients," in the discharge of their knowledge and skill, "by ensuring that duties assumed by or assigned to other occupational therapy personnel match credentials, qualifications, experience, and the scope of practice." Through these actions, occupational therapists can truly demonstrate that they do not acquire their knowledge for, "personal gain, prestige, or power. Rather, the profession holds this knowledge in trust for the good of the sick." (Pellegrino, 1991 p. 114)
Finally, occupational therapists also make a public pledge to promote the well being of others through the Occupational Therapy Code of Ethics (2000). The Preamble to the Code states: "The American Occupational Therapy Association and its members are committed to furthering the ability of individuals, groups and systems to function within their total environment." (AOTA, 2000, in press) Principle 1 of the Code further supports this pledge for the "well-being of the recipients" of occupational therapy. Finally, the dedication of occupational therapists to the well being of those they treat is echoed in the core value of altruism: "the unselfish concern for the welfare of others. This concept is reflected in actions and attitudes of commitment, caring, dedication, responsiveness, and understanding." (AOTA, 1993, p. 1085)
This understanding of the duty of health care professionals to treat patients as drawn from the perspective of occupational therapy can provide some guidance for the initial concern of patient abandonment. There is, indeed, a strong claim here to treat all patients to the fullest of one's ability as an occupational therapist. The two limiting factors to this are when a more competent therapist is needed, and when the patient's actions make further treatment imprudent. But aside from such cases, both the Occupational Therapy Code of Ethics (2000) and the Core Values and Attitudes of Occupational Therapy Practice challenge occupational therapists to act from a higher level of responsibility than the general norms of society. Thus, even though it may be standard practice to refuse to serve customers and clients at one's discretion in business, occupational therapists have a higher standard to follow. Prudential decisions will need to be made about initiating or ceasing treatment when such actions are valid and necessary. However, to avoid the genuine abandonment of patients, occupational therapists must act according to both the letter and the spirit of the Occupational Therapy Code of Ethics (2000) and the Core Values and Attitudes of Occupational Therapy Practice. Penny Kyler sums up these points well when she writes:
As ethical health care practitioners, we are guided by the fundamental belief in the worth of our clients. This belief is based on our social responsibility, as stated in the AOTA Code of ethics and in the Standards of Practice. An ethical practitioner treats clients and delivers services not simply because of a contractual agreement, but because of a social responsibility to do so. (Kyler, 1995, p. 176)
Conclusion: Abide, not Abandon
As Ruth Purtilo notes, the actual physical abandonment of patients by health care professionals is no longer as prevalent as it had once been. However, she adds that, "psychological abandonment often replaces what used to be experienced as the more obvious bodily abandonment of the patient." (Purtilo, 1993, p. 156) Psychological abandonment still involves treating a patient, but in a such a manner, "that the patient becomes a total non-person to the health professional." One of the dangers here is that physical abandonment is rather obvious and can be empirically validated. Psychological abandonment is far more subtle, and may even occur without the practitioner's conscious knowledge, for example, as a type of defense mechanism in a difficult case. Nonetheless, even this form of abandonment must be guarded against. But how? Purtilo offers a simple, but thought-provoking suggestion. She explains that the, "opposite of abandonment is to stay with or abide with the patient." Learning to abide with those in need, those who are difficult, those whose actions appear immoral to us, those whom we fear because of their specific health problems, will certainly not be easy. However, as Purtilo notes, health care professionals, "can overcome their tendency to flee (physically or psychologically) only when the attitude of compassion is combined with an understanding of how much harm is induced by abandonment." (Purtilo, 1993, p. 157)
Learning to abide with the recipients of occupational therapy may be one of the most important ways to safeguard against patient abandonment.
References
American Medical Association.(1994) American Medical Association's Principles of Medical Ethics. In, Beabout & Wennemann's Applied Professional Ethics. New York: University Press of America, Inc. p. 101.
American Occupational Therapy Association (1993). Core values and attitudes of occupational therapy practice. American Journal of Occupational Therapy, 47, 1085-1086.
American Occupational Therapy Association (2000). Occupational therapy code of ethics (2000). American Journal of Occupational Therapy (in press).
Arras, John D. (1991) AIDS and the duty to treat. Mappes & Zembaty, Biomedical Ethics. (3rd ed.) (p. 115-121) St. Louis, MO: McGraw-Hill, Inc.
Beabout, Gregory R. & Wennemann, Daryl J.(1994) Applied Professional Ethics. New York: University Press of America, Inc.
Joint Commission on Accreditation of Healthcare Organizations (1998, January) Comprehensive Accreditation Manual for Hospitals: (p. HR-21-22).
Jonsen, Albert R. (1995) The duty to treat patients with AIDS and HIV infection. In, Arras & Steinbock's Ethical Issues in Modern Medicine. (4th ed.) p. 97-106 Mountain View, California: Mayfield Publishing Company.
Jonsen, Albert R., Siegler, Mark, and Winslade, William J.(1998) Clinical Ethics. 4th edition. St. Louis, MO: McGraw-Hill.
Kyler, Penny, (1995). Ethical commentary. Commentary on Chapter 10, Contracts and Referrals to Private Practice, In Bailey & Schwartzberg's Ethical and Legal Dilemmas in Occupational Therapy. p. 174-176. Philadelphia, F.A. Davis Company,.
Pellegrino, Edmund D.(1991) Altruism, self-interest, and medical ethics. In, Mappes & Zembaty's Biomedical Ethics. (3rd ed.) p. 113-114. St. Louis: McGraw-Hill, Inc.
Purtilo, Ruth (1993). Ethical dimensions in the health professions. (2nd ed.) Philadelphia,: W.B.Saunders Company.
Southwick, Arthur F.(1988) The law of hospital and health care administration. (2nd ed.) Ann Arbor, Michigan: Health Administration Press.
John F. Morris, PhD
Member-at-Large, Standards and Ethics Commission
Last Updated: June, 2000
