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Refusing Treatment to the Overweight: A Case Analysis

It was recently reported that a doctor in Shrewsbury Massachusetts refused to treat a patient named Ida Davidson because she was overweight. Dr. Helen Carter recently decided to stop admitting patients who weighed over 200 pounds to her practice, justifying her decision by citing three incidents in which her co-workers were injured in the course of caring for obese patients. These incidents led Carter to claim that the office in which she carries out her consultations is “unable to accommodate a certain weight”. She also pointed out that the nearby University of Massachusetts has a dedicated obesity centre which is far better equipped and better staffed to deal with obese patents.

Many reports of this story point out that Carter is fully within her legal rights to refuse treatment. For example, both of the articles cited above point out that the American Medical Association (AMA) decrees that both patients and doctors are allowed to “exercise freedom in whom to enter into a patient-physician relationship.” However, it should be acknowledged that the AMA imposes a limit on this freedom by stipulating that:

“. . . physicians who offer their services to the public may not decline to accept patients because of race, colour, religion, national origin, sexual orientation, gender identity, or any other basis that would constitute invidious discrimination.”[1]

The above passage makes no specific reference to weight as a possible basis for invidious discrimination. This may lead one to suppose that by refusing treatment to obese patients, Dr. Carter is taking advantage of an apparent loophole in the AMA code of ethics, and is refusing treatment on a discriminatory basis which the AMA has failed to adequately protect against.

However, although reports of this case may seem to insinuate that Carter’s decision can only be ethically justified by the AMA’s stipulation that doctor’s should have the freedom to decline to enter into a doctor-patient relationship, it should also be acknowledged that the AMA also stipulates that

“. . . a physician may decline to undertake the care of a patient whose medical condition is not within the physician’s current competence.”

This seems plausible, and is a principle that is also enshrined in the British General Medical Council  code of ethics.

Moreover, when we return to Carter’s professed justification for refusing treatment to Ida Davidson, she seems to appeal to notions related to lacking the competency to provide adequate treatment in her current environment. Although Dr. Carter might have the appropriate medical knowledge to provide treatment, the cited reports relate that Carter claims that her consultation room is so small that it cannot accommodate overweight patients without exposing her staff to an unacceptable risk of injury. This seems entirely possible; if providing a treatment to an overweight patient requires physically manipulating the patient, then that treatment may pose a risk to healthcare staff which is not posed by providing the same treatment to patients who weigh less. Moreover, Carter also pointed out that three of her staff had recently sustained injuries whilst providing treatments to obese patients. Assuming that healthcare staff are not required to provide treatments which expose them to a high risk of significant injury, then it seems fair to say that Dr. Carter and her staff lack the competency to provide certain treatments to obese patients in their current environment, in so far as providing such treatments in their current environment would involve exposing staff to an unacceptable risk of injury. If it is right to claim that they lack this competency, then it seems that Dr. Carter’s decision to refuse treatment might be ethically justifiable, if we also presume that she does not have the means to change her consultation environment.

The problem with the ethical assessment of Dr. Carter’s conduct in this case is that there are at least two important facts missing from the various reports on the incident which will help reveal the extent to which Dr. Carter lacked the competence to treat Ida Davidson, and her actual motive in turning Ida Davidson away. First, it is not clear what sort of treatment Ida Davidson was seeking. Clearly, not every sort of treatment requires a healthcare worker to manipulate the physical position of the patient, and it seems that Dr. Carter is competent to carry out such consultations in her current environment. For example, suppose that an overweight patient was concerned about a carcinogenic mole on her nose, or that she wanted to discuss mental health issues; neither of these consultations would require the sort of physical manipulation that would expose healthcare staff to risk of injury.

Second, although the newspaper reports tell us that Dr. Carter turned Ida Davidson away, they do not tell us at what point. If Dr. Carter had turned Ida Davidson away because of her weight without even inquiring as to the reasons for her requesting a consultation, then Dr. Carter’s conduct seems ethically questionable; it might plausibly be argued that such conduct was indeed discriminatory. If on the other hand, Dr. Carter carried out a rudimentary consultation in which she became aware that the patient required a treatment which would involve physical manipulation, her decision to refuse treatment may be justified by appealing to the concept of competency to provide treatment.

There are several other ethical questions that this case raises; we might question whether the AMA have a responsibility to ensure that doctors are working in consultation environments which are able to accommodate overweight patients. The case also bring to the fore the fact that the AMA code of ethics does not explicitly prohibit discrimination on the basis of weight. These are both topics that are worth moral discussion. However, one important lesson that we can learn from this case is that we should not assume what an agent’s motive is in acting without knowing all the relevant facts, especially if the motive that we are assuming them to have might be deemed ethically questionable. Given the facts that have been related in the media reports on this incident, we simply do not have an adequate basis for ascertaining whether Dr. Carter’s turning Ida Davidson away was in fact discriminatory, or an ethically justifiable decision based on a lack of competence to provide treatment without exposing staff to unacceptable risk of injury.


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4 Comment on this post

  1. A reminder: while we welcome dissenting views in the comments section, we can’t allow any personal attacks or discriminatory/hate speech. Comments that violate our comments policy will be deleted.

  2. First of all great post.
    Secondly I would like to over some quick thoughts on it:
    Is it really necessary to know the reason for the consultation and the timing of Dr. Carter´s refusal to offer such consultation, in order to ascertain that Dr. Carter did not act on the basis of discrimination? The passages from the AMA that you cite refer to either a “patient-physician relationship” or “the care of a patient”, both of which seem to imply a longterm relationship. If Dr. Carter knows a priori that she cannot provide every treatment the patient might need in the future, than I would argue that it is more ethical to turn her away from the start instead of running the risk of “cherry picking” the treatments that she will provide for the patient. It could also be difficult to explain to the patient why you refuse to treat her now, if you have treated her in the past.
    Furthermore it should be noted that a criterion of over 200 pounds does also exclude large muscular and it will include small but overweight patients, and I find it therefore a litte bit misleading to frame this as a case of possible discrimination against the overweight. It would be another thing entirely if Dr. Carter had used the BMI as her criterion.
    And last there remains the economic argument, that if Dr. Carter would start the consultation and than had to abort it once she learns that the patient has a condition that she cannot treat I doubt that the consultation could be billed.

  3. Hi Daniel, glad you liked the post. You raise some interesting points, so I shall try and respond to each.

    First, you are right to point out that the language in tha AMA passage does seem to imply a long-term relationship, and this does raise some issues which I did not address in the post. However, I am not sure what is wrong with choosingwhich treatments to provide to the patient, as long as the physician’s decision is based on her competence to provide that treatment. For instance, physicians often refer patients to specialists for exactly this sort of reason. Now, the case of the 200lb patient is different because there is likely to be some embarassment on the patient’s behalf if the doctor is unable to offer certain treatments becaues of her size. With this in mind, I take your point to be that it would be more ethical to turn her away from the very start in order to avoid this embarassment.But it seems to me that the physician would still have to justify this act of turning the patient away, and this justification will again refer to the patient’s weight, and thus not save her this embarassment. On the other hand, if the physician at least consults the patient beforehand, there is a chance that the physician might be able to provide the particular treatment requested, and the issue of weight (and the accompanying embarassment) need not arise.

    Second, you are correct to point out that the criterion of refusing treatment to a certain weight does not necessarily imply that treatment is being refused to all and only overweight patients. The main reason I phrased the issue in these terms is because I was responding in part to how the case has been reported in the media.

    On this point though, it would be interesting to hear from front-line care-givers about whether providing treatment to patients who weigh 200lbs but have a low BMI is less difficult than providing treatments to patients of the same weight with a high BMI. There may be reasons why it would be; for instance it seems plausible to suggest that patients with a high BMI would have less muscular strength to manipulate themselves in certain ways. If ‘high weight but low BMI’ patients could manipulate themselves, and physicians did not face unacceptable health risks in manipulating ‘low weight but high BMI patients’, then the issue would just relate to ‘high weight AND high BMI patients’.

    With regards to your last point, you are probably correct; perhaps though, if doctors could not charge for these consultations, rather than justifying their turning the patient away, this ought to act as an incentive for their having better consultation rooms!

  4. The solution would be to prescribe the lady slimming down as part of treatment.
    Here the point is: unlike gender, race and sexual orientation, obesity is a matter of health. Recommending a diet is not discrimination.

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