The Ethics of Stupidity: Should a Good Doctor Refuse to Treat an Obese Patient?

Several folks have been kind enough to point out this story, and suggest that I may have an opinion on it:

[A woman from] Shrewsbury, Mass., claims that Dr. Helen Carter, a primary care physician at the UMass Memorial Medical Center in Worchester, refused to treat her because she is clinically obese…

It seems the good doctor has decided not to care for anyone (it is unclear if the prohibition applied to all patients or just to females) weighing over 200 lbs. Apparently there was a nearby specialty facility capable of caring for obese patients, so no one was being sent away with no resource to medical care.

There is nothing either illegal or unethical about this policy, according to the AMA and others. Much hullabaloo has ensued in the various comment trails, with many people stating that it should be (illegal. unethical, or both.) They are wrong. The only thing this physician has done is set her weight limit unreasonably low.

Here are the magic words: Scope of Practice. It means that doctors have not only the right but the ethical and legal responsibility to limit the care they provide based on their capabilities, their training and their experience, which together also translate to “comfort level”.

Lots of commenters ranted about “discrimination”. The problem is that one person’s “discrimination” is another’s scope of practice. Do gynecologists get blasted for refusing to care for 50% of the population? Why aren’t pediatricians condemned for transferring their patients out at 18 or 21 or 25 or whenever? What about Family Doctors who refuse to see kids under 11? (They’re just wusses, IMHO, but does anyone accuse them of being unethical?”)

What if I refer a diabetic whose blood sugars are persistently greater than 500. Am I discriminating against diabetics, or am I being a responsible clinician? What about someone whose sugars are over 300? 200? At some point, I’m just being lazy, but the point is that there are limits.

Look at the weight issue like this: re-write the whole story, except change the weight mentioned to 700 lbs.

I know I couldn’t take care of someone that big. My scale doesn’t go anywhere near that high (even with my special trick). My blood pressure cuffs are too small, as are my exam tables. My waiting room furniture is pretty sturdy, but I’d worry about collapse (with ensuing injury to the patient). If I were near enough to refer patients to a specialized bariatric site, I’m sure everyone would agree that it would be appropriate.

What about a patient weighing 500 lbs; same deal, pretty much. 400? Getting closer. 300? There are plenty of people who weigh that much without being clinically obese at all. Tall people; athletes. Definitely well within my scope of practice.

The question is NOT “where do we draw the line”, but rather admitting that drawing a line somewhere is logical, as well as ethical and legal.

The reason the AMA’s position is that,”…patients and doctors can “exercise freedom in choosing with whom to enter into a patient physician relationship…” is because just becoming a professional doesn’t mean you lose your autonomy. I know doctors who refuse to care for patients who smoke. (I would love to refuse to care for stupid people, but I’d probably starve.) Mark my words: you are going to see more and more doctors refusing to take care of people whose blood pressures, sugars, and other chronic diseases remain uncontrolled, in order to increase their “quality” scores (and presumably their income).

There are good and bad reasons for refusing to care for certain groups of patients. Weighing over 200 lbs is not a particularly compelling one, though plugging in some other number would be. Just don’t go confusing “stupid” with “unethical.” Dr. Helen Carter of Worcester is guilty merely of the former, though not the latter.

Dinosaur MD (aka, Lucy E. Hornstein, MD) is a solo-practitioner in Family Medicine. She is also a book author (Declarations of a Dinosaur) and posts frequently at her blog, Musings of a Dinosaur, where this post first appeared.

27 replies »

  1. Mistreatment of a patient because of their weight is not only discrimination, it’s inhumane. Health care is a basic human right!

  2. It’s tragic how Doctors and anyone in the health care field, for that matter, still hold on to this outdated notion that obesity is the patients fault of their own. Also, their advice to just, simply exercise more and dieting, as the only solution, just goes to show their utter indifference of these so-called medical professionals, rather than understand obesity as a legitimate disease. They should treat it as such. Moreover, many obese patients really tried exercising and dieting with no success. It’s not a lack of willpower or gluttony. Some diseases contribute to weight gain, i.e, Cushings Syndrome. Many medications have side effects of weight gain. Their are many contributing factors that the patient has no control of.

  3. Shame on these doctors. They should have their licenses revoked. How can anyone in the health care field get away with this. Such discrimination is heartbreaking and it’s disgusting! Where did these Doctors get their medical licenses; from a Cracker Jacks box?

  4. I do understand limits on practice, but these should be discussed upfront. I booked an appointment with a medical doctor for specific testing (referred). I met the doctor’s policy of completing all health information 10 days before the appointment. I was upfront at this time about my age, height, weight, etc. I called the day before my appointment to confirm that everything was in place. On the day of the appointment, the doctor met with me and then refused to proceed with the testing. He made several disparaging comments about my weight. I agree that I am overweight. I have a diagnosed thyroid condition and am following my doctor’s recommendations to address this issue. The doctor refused to treat me and then I was billed for the appointment (i.e., he billed me for the ‘visit’ in which he refused to treat me.) There should be some recourse to protect patients against this.

  5. Boy, you MDs would never survive being veterinarians. We not only have to take care of obese animals, we have to continue to care for them to the best of our ability even after they bite, scratch, and in some cases quite literally attempt to kill us (try having a 200 pound Mastiff lunge at your face and miss by a fraction of an inch). I have never known a vet to withhold care for any of those reasons. It is considered part of the job, and we make ridiculously low salaries compared to you guys. You might not recognize your actions as being unethical, but in truth they are. Yours is supposed to be a service profession, not a rake in the dough the easiest way possible profession. The more I learn about the human medical profession, the more I hold you in contempt.

  6. I do get that a doctor has limits…and rights to refuse….but the humiliation tactic is what I object to…and the failure to suggest an alternative action going forward…that is not a doctor exercising his/her right to refuse…it is a doctor being a bully, being crass, being a jerk, and simply and doctor not being a doctor….where has professionalism gone? Where has caring gone? For all the advances in medicine and technology the human factor seems to be lost…that will be the end of medical care .. You might as well take the word ” care ” out of it….because “care” and caring apparently no longer apply to the profession.

  7. I was receiving medical care from my internist for 11 years. Pretty good..found Hashimoto Thyroiditis in me and started me on Levoxyl. I Walk 1 to 3 miles a day on treadmill and live on a working farm. My doctor is in the city, btw. In the last 11 years since starting Levoxyl I have gained close to 100 lbs. I do not eat Bon bons,Pop tarts, or HoHos all day..or even part of the day. I drink a Slimfast for breakfast and an Ensure for lunch and eat a normal dinner. I am a retired pro musician, almost 60 yrs old, and a grandmother of three. In my 12th year..this year ..with this doctor ..I went for my annual exam..he barely looked at me..asked some questions about my insurance, job, husband, singing career, etc……with every answer he responded with a negative, insulting, derogatory comment. By the end of the “exam” I was totally humiliated. My weight is 256 and I am 5″4′. My vitals have always been excellent..surprisingly..and after humiliating me my doctor simply said “well, continue what you are doing” ! He also was busy trying to figure out the new computer system the whole time he was “examining” me and used a couple of curse words during the “exam”. Maybe he was having a bad day .. I do understand he is human. But I felt my doctor was being hostile toward me and frankly I am afraid to go back to him. I would get it if he said I needed to lose weight and let’s work on that with this plan..or let me send you to a specialist that can help you achieve this goal ….. But he never has….he just humiliated me and told me to go do what I am already doing….what is that? If I want to be humiliated all I have to do is go home…or clothes shopping. Humiliation is one reason obese people get that way…why on earth would a doctor contribute to that? If it is a psychological issue then send me to that kind of doctor..or maybe an endocrinologist…if he wants to lighten his patient load and get rid of the fat ones why doesn’t he just suggest I see a different doctor? My appointment this year is coming up….I don’t want to go ….I want to drop out of healthcare altogether now….My doctor ought to be on my team, I think….is that really too much to ask? With a doctor like this one I don’t need any enemies!

  8. many older patients have been treated by a certain group of dr at the same hospital which the patients feel the treatment is very good. now this group of dr will no longer treat the patients unless they go to another hospital. is this legal and how can they live with them selves?

    thank you

  9. This is just another excuse for doctors to ignore the patient, not do their jobs and be like”hey fatty loose some weight”. I have heard it all and it is especially fun when an obese doctor says you aren’t trying. I was diagnosed with Hashimotos Hypothyroidism 6 years ago at 150 pounds. Automatically thrown on Synthroid and have gained over 100 pounds. I have discussed the hypo issues with various doctors only to be ignored, have my meds raised and told to loose weight. The internist I am seeing now listened to me, and I was right. This “fatty” was on a medicine that she didn’t metabolize for 6 years. So basically I wasn’t being treated. Don’t judge people by their weight one day it could be you begging for help and telling people you don’t eat HOHO’s all friggin’ day! I think it’s a good thing the dr set the standard, obviously she is not competent enough to deal with real patients. Do the patients a favor though drs. let us all know upfront that you’re judgmental douche-bags it’s best for everyone involved..

  10. It’s really a great and useful piece of info. I’m satisfied that you shared this helpful information with us. Please keep us informed like this. Thanks for sharing.

  11. I am reading these comments and can’t believe my eyes…this is your job…what you chose for your career…to care for people. It is abhorrent to suggest that it is ok to pick and choose the healthiest patients to treat. These people need help! Obesity or the like may not fall in your wheelhouse, but yo can still take them as a patient and help to guide them to more helpful resources. Clearly none of you have ever been severely obese, there is already enough shame and humiliation to go with it. To deny someone that is trying to help themselves might just be enough to send some people off the deep end . IT IS INHUMANE. Everyone has issues, for some it is weight. I should hope that when need help and compassion during the trying times in your life that you are able to get proper care and compassion from others. SHAME ON YOU!

  12. I was a patient who was 100 lbs. + obese for 25 years with an undiagnosed (in spite of seeing over 100 doctors) pituitary tumor that gave me a life-threatening condition called Cushing’s Disease.

    Based on my experience, I think it’s important to ask why Dr. Carter refused to treat the obese patient. Was it because the patient wanted to be treated specifically for obesity, or did the patient want an internist for general care? If the patient wanted general care, then scope of care is no excuse for biased behavior from her doctor.

    In addition, if the cause of a patient’s obesity has not already been established in the health record, or has not been documented and verified by more than one physician, then it is the responsibility of the doctor to investigate the cause of the patient’s obesity. Even then, if the condition does not seem to be managed, perhaps there are multiple, overlapping causes that need to be considered, such as obesity first caused by a thyroid condition, which then causes disability, which contributes to obesity.

    In these cases, doctors are doing a grave disservice to patients when they assume it is only their behaviors that contribute to their obesity, and that they will be non-compliant or show lack of improvement. They may indeed save the patient from additional suffering by being the first physician to take them seriously.

  13. As a former high school teacher, I can relate to this. I would have loved to refuse to teach kids who would not do their work, slept in class, and didn’t listen to instruction or study. And it wouldn’t be just to pump up my scores. It’s just that there is nothing more frustrating than trying to work with someone who will not follow suggestions to make things better, such as their grades. Kids can sit in class and not do one single thing, and then lament the fact that they end up failing. All of a sudden they want to do “extra credit,” when no amount of work can save a grade that has fifteen zeroes and 5 failed tests in a six weeks period. I’ve often thought that doctors must get very annoyed when dealing with patients who won’t follow advice, lose weight, quit smoking, or take their medicine properly. I think the 200 pound limit is too strict, but I definitely support her for not wanting to deal with someone who will most likely someday have ailments beyond the doctor’s area of expertise. It was beyond my capabilities to make unmotivated, defiant, or potheaded students suddenly want to improve their grades. It’s beyond a doctor’s expertise to make patients want to lose weight. That’s for the psychologists. Unfortunately,public school teachers don’t have a choice, and we struggle to address these kids in a class of 30, with 25 or so who want to learn. The five who don’t often spend their class time trying to engage or distract their friends who do want to do well. After exhausting all the tried and true methods of trying to pull these kids in, it’s no wonder that teachers sometimes become apathetic about students who resist every tactic. It’s usually very obvious after parental phone calls that the parents have given up. I’m sure it’s the same with doctors who deal with patients who steadily gain more weight and then develop high blood pressure, diabetes, joint problems, and everything else associated with obesity. It must seem pointless.

  14. Appreciate an apology, if you read an article in the Washington Post today regarding how Medicare is going to basically punish hospitals and doctors for not curing people and thus preventing readmissions, well, you may unfortunately see more limited scopes in care much to the detriment of those who would benefit with time.

    Even if some have to return to the hospital. PPACA is going to do as much harm as good as written now.

  15. DeterminedMD, I’m sorry, but I think you misunderstand me. I don’t think that doctors should take a vow of poverty. I agree with dinasaur MD. I understand that doctors need to protect themselves. I am merely saying that I think Dr. Carter’s scope of practice is very limited, and that if most doctors were so limited in their scope of practice a lot of people would be without healthcare.

  16. Ouch, what does that last sentence infer?!

    Last I checked, can’t find those sentences in that alleged contract I signed on the day I finished Med School that said I took a vow of poverty, and, anyone who walks in the door gets full service without any boundaries or challenges.

    Jeez, you antiphysicians really think physicians are slaves to the for profit system that non physicians are trying to ram down throats and other sphincters. Gimme a break, can’t stand people who hold others accountable. Not the democrat way, eh?!

    What’s next to be revealed in your bill, NANCY P?!

  17. What about when science says that eating highly processed high carb foods causes obesity and diabetes? Do doctors and the AMA have an obligation to tell the government (and patients) that the food pyramid (or plate) is the cause of our ills?

    Talk about stupidity, but I guess it’s in the same spirit as when doctors used to recommend cigarettes for better health.

  18. Scope of Practice only becomes a problem when most doctors decide to be so limited in their scope. Then the people who are really sick, financially challenged, less educated, over 200 pounds, etc… are really in trouble.
    Luckily, I don’t think that most doctors are so limited in their scope as Dr. Carter.

  19. If you take care of sicker patients,
    financially challenged patients,
    less educated patients,
    stressed and depressed patients,
    english second language (or no english at all) patients
    more than your colleagues do, you are doing good things for humanity.
    And you will be labeled a “low quality” doctor because of it.

    good times, good times.

  20. so, health plans work to eliminate or at least reduce their risk all the time. Why shouldn’t doctors? I fail to see the difference here.

  21. In the team-based paradigm of health care delivery, leverage of the new- model agenda will allow rapid cycle facilitation impacting the end-point of our mutual journey.

  22. Since we’re “transforming” medical practice to provide “health care instead of sick-care”, I think all doctors should only agree to see healthy people. Quality measures will soar…. and we’ll have tons of money to pay for performance….

  23. Just watch out for the antiphysician lobby that seems to run these threads, ’cause they just love it when physicians try to remind the population that we do have the right to autonomy. Frightens the hell out of the PPACA lobby.

    Again, we as doctors do not wear a black collar with a white square in the front. Stop confusing us with priests, please!