AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. September 2001, Volume 3, Number 9.

Cases in Law and Ethics

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Obligations to Noncompliant Patients

An ethical case explores whether a physician who wants to terminate his professional relationship with a noncompliant hemodialysis patient has an obligation to treat the patient if the patient has a disability.

Faith Lagay, PhD

After treating 19-year-old David E. for chronic renal failure for several years, nephrologist Dr. T. became exasperated and told David he wished to terminate the therapeutic relationship because of David's abuse of alcohol, failure to take his prescribed medication, frequently missed hemodialysis appointments, and repeatedly disruptive behavior in the clinic when he did show up for treatment.

David E. sought a court order to block Dr. T's termination of the relationship, in essence, an order compelling Dr. T to provide treatment including the necessary hemodialysis. Noting that physicians are free to choose whom to serve and that hospitals can only be compelled to treat in cases of medical emergency and active labor, the court ruled that Dr. T. could terminate the relationship and that the hospital was not required to offer David E. hemodialysis if he continued his disruptive and non-compliant behavior.

David E. lived in a mid-sized city, and word of his case spread among the medical community so that is was difficult for him to find a physician and hospital for his required treatment. He appealed the court's decision. On appeal, Mr. E's attorney claimed that his chronic physical illness resulted in severe depression that constituted a psychiatric disorder, and that this psychiatric disorder was the cause of Mr. E's non-compliance and disruptive conduct.

The Americans with Disabilities Act (ADA) of 1990 defines psychiatric illness as a disability. Mr. E's attorney argued that to deny David E. treatment because of his non-compliance would be denial based on a psychiatric illness or disability, a denial prohibited by ADA.


  1. Does the cause of David E's conduct—psychiatric illness versus a rational decision that the medical restrictions are not worth the trade off—alter Dr. T's ethical obligation to his patient?
  2. If the appeals court, considering the ADA defense, orders Dr. T. to treat David E, will that decision violate the physician's freedom to choose whom to serve?
  3. Is chronic need for life sustaining medical treatment (e.g., hemodialysis) the same as emergency need? Do laws and policies that compel physicians and hospitals to provide emergency care encourage patients with chronic illness to let their conditions reach acute crises in order to get care on demand?
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