Has a patient asked you to ‘bend the rules’? Here’s some guidance on unreasonable requests
Patient pressure can sometimes be difficult to withstand, particularly when there is a clinical need. How the law can help and tips to navigate these ethical dilemmas.
Wednesday, 5 March 2025
“Jake seemed quite distressed during the appointment. I provided him with referrals, as I was worried about the knee mass and did not want to expose Jake’s father to any more radiation.”
This seemingly uncontroversial statement was made by a GP during tribunal proceedings in a case recently handed down by the Victorian Civil and Administrative Tribunal, and reported in AusDoc last month.
The case involved a radiographer who performed scans on his elderly parents, who were visiting from overseas and ineligible for Medicare benefits.
The radiographer performed the scans at his place of employment without his employer’s knowledge and without the appropriate referrals.
When his employer discovered his conduct the same day, the radiographer pressured the GP into providing retrospective referrals for the scans which he had already carried out.
The GP told the radiographer that this was not the correct process, but nevertheless provided the referrals because of the radiographer’s distress and the elderly father’s clinical situation.
Faced with this situation, where there is a conflict between ethical obligations and values, what is the right thing to do?
On the one hand, providing a retrospective referral is dishonest and conflicts with values such as integrity and professionalism.
On the other hand, providing a referral would mitigate the radiographer’s distress and the risks of exposing his father to further radiation, consistent with the obligation to act in the best interests of the patient and the value of compassion.
In writing the referral under pressure from the radiographer, the GP put themselves at personal risk of a disciplinary complaint or other action, but for this GP in this situation, compassion trumped compliance.
Most doctors will have faced situations where they feel pressured into doing something that conflicts with their personal values and/or professional obligations, and responses to ethical dilemmas can range from discomfort and stress to moral disquiet and moral distress.
There are some textbook ethical dilemmas, such as whether to be involved in a late termination of pregnancy, voluntary assisted dying, or withdrawing or withholding life-sustaining treatment.
But smaller everyday situations, like the one faced by the GP in the tribunal case, can equally result in discomfort and raise questions around the ethically appropriate approach.
Other examples include being pressured by a family member to provide a regular script, providing a back-dated medical certificate for sick leave, or undertaking a procedure on a patient where there is limited clinical evidence of benefit.
Pressure by patients to do something unethical, unreasonable or unlawful can sometimes be difficult to withstand, particularly where there is a clinical need.
But compassion will rarely be a legal defence.
The law can help in some situations: a legislative right to conscientiously object or a statute that makes certain conduct an offence (for example, forging a prescription or making a false Medicare claim) is a handy ‘out’ when a patient is pressuring you to do something you do not agree with or is not legally permitted.
There are other practical tips available for when it is hard to say no.
Having a framework within which to make decisions can also help navigate ethical dilemmas. The NHMRC’s Clinical Ethics Capacity Building Resource Manual refers to several different frameworks that can be used to structure ethical deliberation.
Clinical ethics support may be available in hospitals and larger institutions, but even in smaller organisations, including medical practices, having a colleague or adviser to talk through the ethical dimensions of a problem can help.
Calling your MDO to discuss the situation can also help to sense-check your reasoning and approach.
Ultimately, you should always comply with the law.
There will be times in your practice when you face an ethical dilemma or conflict between ethical obligations and values.
If you don’t know what to do, seek advice.
This article was originally published in AusDoc on 21 February 2025.
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The case discussed in this article is based on a real case. Certain information has been de-identified to preserve privacy and confidentiality.
IMPORTANT: This publication is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practise proper clinical decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published.
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