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View Full Version : Obligation for physician to treat a homicidal patient?


raburrell
01-20-2010, 08:27 AM
My google-fu is failing, because all I'm coming up with are refusal-to-treat guidelines based on financial considerations. Anyhow...

1. Female physician, off by herself in an unfriendly area. No immediate access to other individuals, trained or otherwise.
2. Her patient (a not-nice individual) is experiencing a medical emergency (tension pneumo). She relieves the pressure, and he attacks her. In the process, the chest drain she put in is ripped out, and he relapses.

My question, for the doctors/medical professionals here: If she truly believes he'd kill her, is she obligated to continue attempts to treat him?

Abandoning an emergent patient is obviously a giant no-no, and she's a very committed physician. Yet professional obligations to her patient shouldn't extend to the point of suicide, right?

Whether yes or no, I'd be truly grateful for some insight on what she might take into consideration at that moment.

Exir
01-20-2010, 08:57 AM
What kind of attack is this? Is it threatening her life?

raburrell
01-20-2010, 04:58 PM
Yes, absolutely - they're in a smuggling tunnel, he's wielding a pickax (or maybe a shovel), and he's made it clear he intends to use it. He's also already injured both the doctor and the other woman she's down there with.

JimmyB27
01-20-2010, 05:21 PM
If there's no-one else around, surely the question that's more important is 'what would your character do?'. If medical ethics say treat the patient, and she doesn't as she's too afraid - who's to know?
Anyway, I can't really imagine anyone blaming a woman alone in a potentially dangerous environment with a definitely dangerous patient who's already proven his intent three times for abandoning him.
Though, having said that, the world is a bloody stupid place sometimes - I bet any surviving relatives would sue her.

raburrell
01-20-2010, 05:31 PM
Thanks, JimmyB.
She's an aid worker in the West Bank, and the guy is a Hamas fighter, so you're right, chances are, no one would know and fewer still would miss the guy. For that reason, I'm more worried about whether or not the MC should be able to justify it to herself.

RJK
01-20-2010, 06:00 PM
I'm not a physician, but I've seen doctors refuse to treat people for less reason than you describe. In one case, a head injury patient was allowed to expire, rather than attempt heroic surgery. In another, an emergency patient needed reconstructive surgery, no reconstructive surgeons could be located, and the other doctors and surgeons refused to stitch him up. (They feared malpractice suits if they put the patient's face back together wrong.)
In your case, I think personal safety would win out over Hippocratic Oath.

Wiskel
01-20-2010, 06:08 PM
It's an interesting dilemma.

There is no legal obligation to treat but there is always the possibility of legal repercussions......leagl action doesn't have to be justified to occur and she's got a very good defence if she has to justify it. If she was the doctor who had been sent to the site specifically to treat the man then that does carry an obligation to do her job. If she just happens to be there then there is no obligation at all.

For her personal dilemma, she needs to explore her options. Could she tie the man up and make it safe to treat him?.....bandages would be pretty useful for this, or does she have anything on her that would sedate him?

You've created an interesting situation bu giving her the materials for a chest drain. That needs a fair bit of kit...even if it's improvised. You wouldn't find one in a typical household first aid kit.

If she is carrying a genunine chest drain it suggests a medical kit is close at hand and the sort of kit that would be handy to have as a combat medic is likely to contain strong painkillers and possibly even sedatives. She might have the tools to chemically sedate him but with the downside that painkillers can reduce respiration and make a pneumothroax potentially more dangerous.....time is also a major factor in this situation and the sedatives might not have time to work before he expires.

In the end it's going to come down to her character. Doctors do sometimes take it hard when they can't treat someone but they're also pretty good at detaching themselves and accepting that they can't do anything.

Craig

raburrell
01-20-2010, 08:03 PM
She's got the equivalent of a field-trauma kit, yes, and I did wonder about the possibility of sedating him, but he's standing between her and the kit. She'd previously gotten as far as getting a flutter valve attached and told him he'd need to get to a hospital right away for further treatment. Essentially, he assumes he's okay at that point & that's when he goes after her. So I think it'd be reasonable to assume if she patched him up again, he'd only keep after her.

I think what I'm hearing is abandoning him could be justified from an outsider's perspective, so it's more a question of making herself realize there's nothing she can do.

Thanks

Kitty Pryde
01-20-2010, 09:12 PM
It's legal/ethical to avoid personal harm while providing medical care. Even if she was sent there specifically to care for this guy. For instance, I know that in the US, if a paramedic shows up at a house where he knows there's an injured person, if he can hear gunfire inside, it is ENTIRELY both legal and ethical to NOT go into the house. In that case the procedure is to wait for the cops to show up and declare the area safe before going in to provide medical care. Even if he knows someone is inside bleeding to death.

Similar situation: if the doctor knows she'll probably be hurt or killed providing care, she doesn't have to do it.

Of course, I don't know what the laws are in Israel.

raburrell
01-20-2010, 09:25 PM
Thank you, Kitty - That perspective really helps. eta: I did find a rabbinical discussion on the ethics of refusing to treat a patient with SARS during that epidemic. Reasons to follow that Israel's laws would be similar to what was in there.

NewKidOldKid
01-20-2010, 09:40 PM
He's not very bright, is he? Otherwise, he'd be quiet and let the woman save his life, rather than jumping on her the second he can open his eyes.

ETA: oh, I see. Should read the whole thread before commenting.

raburrell
01-20-2010, 09:51 PM
He's not very bright, is he? Otherwise, he'd be quiet and let the woman save his life, rather than jumping on her the second he can open his eyes.

Heh. No, I suppose not. But I think he was afraid she'd divulge the location of the tunnel.

frimble3
01-21-2010, 02:43 AM
If a man attacks his doctor, would that not be 'refusing treatment'? (I'm thinking she's yelled the usual medical advice, "Don't move around, you'll hurt yourself".) In which case, wouldn't her first duty be to the other woman, who you said the attacker had injured?

L.C. Blackwell
01-21-2010, 10:51 AM
Paramedics are not only not required to enter a building where they are threatened, but by the guidelines of many localities, they are forbidden to do so.

The doctor's first duty in such a situation as you've described would be to assure the safety of herself and the other injured people.

ideagirl
01-22-2010, 10:54 PM
Yes, absolutely - they're in a smuggling tunnel, he's wielding a pickax (or maybe a shovel), and he's made it clear he intends to use it. He's also already injured both the doctor and the other woman she's down there with.

No, of course not. Self-defense trumps professional obligations. But remember what they would do in a hospital in this situation: they would restrain the patient, literally strap his arms and legs to the bed. If she has any further desire to treat him in the situation you're describing, I cannot imagine that she would even begin to contemplate doing so unless there's a good way for her to fully restrain him first.

GeorgeK
01-24-2010, 04:17 AM
The Hippocratic Oath is moot. Almost nobody takes the oath anymore and those that do, generally have never even contemplated the implications of it. Hippocrates was by modern comparisons, an apocathery (closer to a pharmacist), not a physician. For his time, he was great, but thank God, those days are gone. Legally and ethically your doctor would be foolish to treat said terrorist because she can do more good by not treating him as opposed to getting killed and being unable to treat anyone else. (assuming she doesn't think he's merely delusionally combative due to pain or whatnot in which case physical restraints and appropriate care would be in order) In short, you could do whatever and be able to reasonably justify it.

raburrell
01-24-2010, 07:38 AM
Thank you, GeorgeK (and ideagirl).
I've read both the original and a few modern rewrites of the Hippocratic Oath while thinking about that scene (which, as an aside, are quite interesting in both similarity and differences). The only thing stopping me was the fact the idiot would die if she ran off. I was reasonably sure what The Right Thing To Do was, but I didn't want readers saying she was a horrible doctor & should lose her license if I was wrong.

Appreciate the thoughts, everyone :)

Tsu Dho Nimh
01-24-2010, 08:21 AM
Abandoning an emergent patient is obviously a giant no-no, and she's a very committed physician. Yet professional obligations to her patient shouldn't extend to the point of suicide, right?

Whether yes or no, I'd be truly grateful for some insight on what she might take into consideration at that moment.

I work in "first response" kind of medical care, and my obligation to continue care stops if the injured patient is putting my life in danger, or the lives of anyone else. PERIOD!

Break out a pickaxe and I'll do what it takes to save me, and any other patients, no matter how badly injured the pick-axe waving one is.