Patients' Responsibilities: I. Duties of Patients

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I. DUTIES OF PATIENTS

Today, popular culture in the United States seems to be stressing health promotion and disease prevention; it is easy to get the impression from many sources that if one does not exercise regularly, eat the proper foods, and avoid tobacco and other dangerous substances, one has failed in a fundamental duty. In medicine and nursing, a vast literature has accumulated on "patient compliance"; despite some reminders that patients ought to be viewed as autonomous agents—the wisdom of the term compliance has been called into question—much of this literature assumes that the patient has a duty to follow advice given by the health professional. By contrast, eighteenth- and nineteenth-century codes of medical ethics, which listed responsibilities that patients owed to their physicians in order to balance the responsibilities that physicians were said to owe to their patients, have been condemned by most modern authors as paternalistic and self-serving. Whether patients owe any duties to health professionals and to others, and the extent of those duties if they exist, remain problematic. The topic has been much less studied in bioethics than the duties owed by professionals to patients and to society.

Duties Owed to Health Professionals

Many helpful models of the professional–patient relationship are based on some variant of social contract or covenant; and those models would imply that patients owe at least some duties to the professionals. These models deny the assumption that underlies most eighteenth- and nineteenth-century codes of medical ethics, namely, that professional ethics is a matter to be decided solely by professionals themselves, with no necessary role for patients in determining the rights and responsibilities that constitute professional ethics. It is this exclusion of patients from defining professional ethics, and not the idea of patient responsibilities per se, that permits the criticism that the alleged responsibilities of patients are paternalistic.

Are there any duties patients themselves would agree they owe to health professionals? Duties that would reasonably fall under this heading are so closely linked to the adequate carrying out of the professional role that their violation would make it impossible for the professional to provide the patient with the care the patient expects and demands. Such duties, properly circumscribed, cannot pose a threat to any patients' rights, because all such rights exist within a relationship whose purpose is to provide the patient with healthcare from a professional. Indeed, Meyer argues that the very notions of patients' rights and autonomy presuppose such a relationship.

Martin Benjamin proposes two such patient responsibilities: (1) honoring commitments, including compliance with a treatment regimen one has consented to carry out; and (2) disclosing relevant information, especially data needed to reach an accurate diagnosis and management plan for the illness. He is careful to insist that no patient has a duty to adopt any treatment plan merely because a professional recommends it; otherwise, there would be no patient right to informed consent. However, once the patient has agreed to try a plan, the patient has an obligation either to continue with the treatment or to inform the professional in a timely manner if circumstances (such as medication side effects) have made it impossible to do so. In this way, we acknowledge both the patient's right to autonomous choice and the professional's need to rely on disclosure of information and honoring of commitments in carrying out the assigned role.

Duties Owed to Identified Others

In general, duties owed to identified others are justified by the nature of the relationship between the patient and that other party. For example, as an extension of the duty to protect the interests of and to avoid harm to members of one's family, patients could have a duty to disclose health information (such as information about communicable diseases and genetic conditions) that would otherwise be protected by the right of confidentiality.

Where it is difficult to specify the precise nature and scope of the relationship, there will be a corresponding disagreement about the duties one owes. For instance, there is controversy about the duties that a pregnant woman owes to the fetus or the unborn child, in avoiding behaviors that might pose a health risk to herself or to the fetus and, in some instances, in either seeking or failing to seek an abortion. Such controversy will be resolved at least in part by more satisfactory conceptions of the precise relationship between the pregnant woman and the fetus or child. For instance, viewing the mother and fetus as two strangers with a conflict of basic interests hardly seems to do justice to the actual nature of their bond.

Duties owed because of specific contractual relationships are much easier to understand and to justify. For example, if an insurance policy does not cover a particular laboratory test unless it is required to diagnose a specific condition, the patient has a duty not to ask the physician to falsify the claim form and say that he or she suspects the condition, when in fact the patient merely wants to know the laboratory value as a screening measure.

Duties Owed to Other Patients Generally

A patient in a modern technological society receives many benefits because of sacrifices made by patients in the past. I could not receive a medication for an infection unless that drug had been tested in research subjects. I could not receive care from a highly qualified physician or nurse unless that professional, as a student, had practiced on other patients, under supervision. It would seem at first glance that I would have a corresponding duty to serve as a research subject or as "teaching material" when I could do so with relatively little risk and inconvenience. But the healthcare system generally regards such participation as fully voluntary, not as arising out of any duty. The difference between these two views may be a result of differences in the level of moral analysis—one may acknowledge that one owes a moral duty as an individual, even if as a policy matter the institution is unwilling or unable to enforce any such duty. A full analysis of the duties, if any, that patients owe in such circumstances may nonetheless hinge upon the general theory of justice one adopts.

Duties Owed to Society

An important debate centers upon whether one's entitlement to healthcare services, or the portion of the cost of care that one bears, should hinge on the extent to which one has adhered to a healthy, low-risk lifestyle—an increasingly difficult task, as science regularly uncovers previously unappreciated health risks.

One proposal to fund expanded healthcare coverage and benefits in the United States, for instance, includes a substantial increase in the tax on cigarettes. This could be justified purely as a matter of public health, since empirical evidence suggests that a number of people will stop smoking as a result of the tax. In turn, the public-health agenda could be justified in part by referring to a patient's duty to himself or herself to avoid serious health risks (though some analytic philosophers would claim that a duty to oneself is incoherent, since if someone owes a duty to me, I can always voluntarily release him or her from that duty), or to the duty that an individual owes to close family members not to abandon them or decrease one's ability to support them by running unnecessary and substantial health risks. Alternatively, the tax could be justified as a matter of justice, with those who voluntarily adopt unhealthy behaviors having some responsibility to pay for a larger share of the overall health costs. According to this latter line of analysis, the tax is therefore justified even if it fails to persuade any current smokers to stop.

Some of the debate about a duty to avoid health risks centers upon the addictive nature of some undesirable behaviors. Addiction implies a loss of voluntary control, suggesting that any duty not to engage in that behavior is correspondingly weakened, assuming that I cannot have a duty to do what I cannot do. On the other hand, a careful analysis of most addictive behavior patterns reveals certain actions that do appear to be under voluntary control, even if other aspects of the pattern seem to be characterized by loss of control. For instance, smokers may elect not to sign up for smoking-cessation counseling, and may socialize in settings where they know the temptation to smoke will be high.

To some extent, linking entitlement to care with a duty to remain healthy depends on where one stands on a spectrum between individualistic and communitarian conceptions of healthcare justice. On a purely individualistic approach, I have no responsibility to help pay for the health needs of anyone else; on a communitarian interpretation, we all have a shared responsibility to provide decent care for all, and that sense of shared responsibility is undermined by efforts to assign differential duties to pay to different citizens on the basis of their personal behaviors. Also, a duty to avoid health risks seems more justifiable when it is applied even-handedly rather than being used to condemn those whose lifestyles differ from one's own. Finally, a policy based on a duty to avoid health risks seems justifiable in inverse proportion to its personal intrusiveness. Thus a tax on the sale of cigarettes appears more justifiable than refusing healthcare to those whose diseases are caused by smoking, or spying on citizens in their homes to be sure that they really have stopped smoking.

howard brody (1995)

bibliography revised

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Encyclopedia of Bioethics