Care for the belligerent patient debated in AMA open forum

Honolulu -- As the AMA Council on Ethical and Judicial Affairs puts together its upcoming reports on several topics ranging from care of belligerent patients to fees and other surcharges for nonmedical services, it will have a wide range of opinions to take into account.

Dozens of doctors stepped forward to express their views during the council's open forum at the AMA House of Delegates meeting here in December 2003.

CEJA members were looking to their colleagues for input on whether the AMA Code of Medical Ethics' obligation to respond to medical emergencies to the best of their ability extended to the belligerent or inappropriate patient.

"The first questions should be what is the cause," said Mike Williams, MD, a neurologist from Baltimore and a delegate for the American Academy of Neurology. "Is the belligerence a manifestation of the patient's disease? If it is, then the obligation becomes higher."

Clifford Moy, MD, a Texas delegate and a psychiatrist from Austin, Texas, asked CEJA to consider redefining belligerence into two categories.

"Not all physical violence is the result of a treatable illness," he said. "I don't believe physicians are obligated to take undue risks. But if someone is verbally offensive or obnoxious, I do believe there is an ethical obligation to continue treating, as unpleasant as that is."

Nonmedical fees, other issues

CEJA is also taking on the idea of adding fees or surcharges for time spent on telephone calls, e-mails, paperwork, etc., and the council was wondering whether physicians were warranted in charging for nonmedical services. Delegates didn't find the charges unethical -- as long as patients knew of them up front and consideration of a patient's ability to pay them was kept in mind.

"The real question is whether we are ethically obligated to let patients know about the charges before the doctor patient relationship begins," said Fred L. McMillan Jr., MD, a Jackson, Miss., ophthalmologist and an AMA delegate. "That lets the patient decide whether the relationship should be formed."

Gaylord Kavlie, MD, a general surgeon from Bismarck, N.D., agreed. "You need to let the patients know," he said. "Make sure the patients understand what they are paying for.

Other topics on the table were physician participation in the treatment of mentally incompetent individuals to restore legal competency to stand trial, incentives to patients for referrals, and isolation and quarantine.