GPs facing reluctant and demanding patients: analysing ethical justifications

BACKGROUND: Several studies have explored the physicians' preferred actions when facing a reluctant or a demanding patient, but only a few studies have explored the physicians' justifying reasons. OBJECTIVE: The aim of this study was to assess how GPs would act and how they would justify their choice. METHOD: A postal questionnaire with questions about preferred actions and justifying reasons was sent to a random sample of GPs in Slovenia (n = 160) and Sweden (n = 200) using four vignettes: (i). a healthy patient reluctant to quit smoking; (ii). a healthy patient demanding an X-ray; (iii). a pulmonary cancer patient reluctant to quit smoking; and (iv). a pulmonary cancer patient demanding immunotherapy. RESULTS: The majority of GPs would bring up the question about smoking with the patients reluctant to quit. They justified their choice by referring to promotion of medical benefit and to protection from harm. Swedish GPs were less inclined to bring up smoking than were their Slovenian colleagues. Those who would not bring up the question referred to respect for self-determination and an enhanced relationship as their justifying reasons. With reference to the demanding patients, a minority of GPs would grant the healthy patient's request for an X-ray that was not medically motivated. The answers were similar with respect to the seriously ill patient requesting non-medically motivated immunotherapy. Slovenian GPs were much more inclined to grant the request than were their Swedish colleagues. Enhancing the relationship and respect for self-determination were the most important reasons for granting the demands. When the demands were denied, the GPs mostly referred to promotion of fair distribution of resources. CONCLUSION: Many of the GPs considered their patients' right to self-determination less important than other values, e.g. the obligation to promote medical benefit, to protect from harm, to distribute public resources fairly and to enhance the patient-physician relationship.