“Respect for the autonomous choices of persons runs as deep in common morality as any principle.” –
TL Beauchamp and JF
Childress, Principles of Biomedical Ethics (2001)
What is the doctor’s role?
A doctor’s primary concern is to do their best for their patients; this includes giving advice and treatment, and arranging investigations in accordance with the current evidence base and the patient’s best interests.
Why can non-compliant patients present difficulties?
All practices will have a cohort of patients whose autonomous choices conflict with the suggested course of action of their doctor. Given that there is no obligation to provide a treatment requested by a patient that is not to their overall benefit, this can give rise to clashes between doctor and patient.
What are the commonest scenarios in relation to non-compliance?
A patient has been started on a treatment, but declines to attend for subsequent review and/or monitoring checks. This scenario puts a GP in an invidious position, in that a decision has already been taken that it is in the patient’s best interests to commence a particular treatment. This can create a new risk that must be balanced when judging what is in the best interests of the patient.
A patient who declines the investigation or treatment of symptoms with a potentially serious and/or treatable underlying cause.
It is important to remember that it is unlikely that a doctor will be legitimately criticised if a competent patient has made an informed decision to pursue a particular course of action.
The Medical Council states that you must respect and support the patient’s right to seek a second opinion or to decline treatment, or to decline involvement in education or research.
If a shared understanding is reached between the doctor and the patient, it can be a cathartic experience.
To protect themselves a doctor must be in a position to justify the approach taken, and to demonstrate that they made the patient clearly aware of the risks of non-compliance. Comprehensive records are essential.
You should end your professional relationship with a patient only when the breakdown of trust means you cannot provide good clinical care. For a diagramatic view of the step-by-step approach to management of a non-compliant patient, please see the flowchart below.
Step-by-step approach to dealing with non-compliant patients:
Good Medical Practice (paragraphs 31 to 34)