Every year thousands of doctorsin training pledge to uphold the principles of the Hippocratic oath through the Declaration of Geneva – a commitment to medical integrity and ethical standards. Of these principles, beneficence and justice are two immutable components. The first obligates the physician to act in the best interest of the patient including caring for difficult patients whilst the latter bids physicians to treat all people equally and equitably. “I WILL NOT PERMIT considerations of age… social standing or any other factor to intervene between my duty and my patient”. With such virtuous declarations, it is no wonder that the integrity of one St.Lucian doctor was recently called into question when the decision to decline care to an underprivileged child sparked public outrage. Was the decision to deny care justified and within reason or was it simply an attempt to protect a wounded reputation? The consensus is that unless the physician-patient relationship has been established, there is no legal obligation for the physician to treat, and if it has been established, special considerations must be made and fulfilled to ensure continuity of patient care.

　　An island paradise, boasting ofnumerous travel and tourism best destination awards, visitors to the picturesque island of St.Lucia would be horrified to know of its growing prevalence of crime. In 2021 alone, St.Lucia saw a 34.3% increase in crime from the previous year, and according to the data collected by the Royal St.Lucia Police Force’s statistical department, homicides and murders have seen a consistent increase over the past five years. More shockingly, deputy commissioner of police at the time, Ronald Philip, revealed in early 2024 that the victims of the surge of violent crimes from 2014 were predominantly young males, with 60% of the fatalities being male and 4% being female, aged 35 or younger. This statistic hit home on October 1st this year when a seven year old girl named Julia was fast asleep when she was struck by stray bullets, sustaining four gunshot wounds, including one to her face. The island nation was rocked by the incident and cries for justice poured out. Once receiving treatment, Julia, now stable, regained her ability to speak, however the road to recovery was far from over as she would need subsequent surgery to achieve full utility of her mouth.

　　Under the coordination ofSt.Lucia’s Chief Medical Officer, the services of a well known local maxillofacial surgeon was employed to conduct a needed procedure. However, this would prove very costly to Julia’s mom Ms. Britteny Paul. Although offers of financial help poured in, it was still not enough. With that in mind, Ms.Paul took to social media to solicit financial assistance as is common practice amongst many less fortunate citizens in need of medical assistance and medical attention especially overseas. A picture of the medical quotation quickly circulated on pages Instagram and Facebook (Meta platforms), garnering the ire and disdain of many who were displeased with the cost. Several persons commented that the doctor should provide their services free of charge as a show of compassion. Others made critical and rude remarks calling into question the morality and conscience of the medical practitioner. To put it mildly, there was quite a stir and this unfortunately would not augur well for the physician- patient relationship.

　　Only a couple days later, newsreports and social media revealed that the mother was alleged that the doctor withheld care after she turned to social media for financial help, posting a document detailing the surgery costs. According to the mother, the doctor told her that she's not going to do the surgery for the child anymore because she doesn't “do social media and Facebook and those kinds of things”. The mother’s distressed pleas that this was her only option in order to generate sufficient funding fell on deaf ears. As stated prior, this was not a strange or unusual practice. Many citizens use the same strategy, although it would seem that none ever incited such emotions and reactions from the public. Of course this did not go down well in the public’s eye and social media once again lit aflame. Sharp criticism quickly followed at the doctor’s decision and calls to step down ensued, with some citizens even suggesting a complete boycott of the services of the private practice. Others went as far as calling for the doctor’s license to be revoked. Could it be that the doctor felt disrespected by comments made online? Could it be that there was a shift in morale considering how their compassion and charity were called into question?

　　With no answers from thephysician in question the St.Lucia Medical and Dental Association only released a statement, stating in part that whilst they deeply empathize with the young patient and her family, they are “deeply concerned by the recent negative comments made on social media by one of our esteemed physicians”. They further went on to urge the public to “exercise caution and avoid rushing to judgment without being fully informed”. The SLMDA warned that “negative, unsubstantiated comments can damage the reputation and morale of dedicated healthcare professionals” and credited the doctor for having previously offered “services free of charge or at discounted rates to many underprivileged Saint Lucians”. More importantly to them, “the ethical action of referring the patient to another specialist had already been made” in this case. The SLMDA emphasized that trust between patients and healthcare providers is vital.

　　Whilst the response by the SLMDAaimed to soften the public’s opinion, it did little to quench the public’s thirst for transparency and justification to the doctor’s decision. Reasonable concerns and questions were asked, “can she do that?”, “what about the hippocratic oath?”. Like many others I too shared similar concerns. Has the patient-physician relationship not already been established? Does the mother have a case for litigation? All these questions ran through my mind. Hence I was forced to take a deeper look into when the physician-patient relationship is established and on what grounds it can be terminated.

　　The physician-patientrelationship is thought to be a contract in which the two parties agree to treatment. Legally speaking, the doctor thus has the right to decline acceptance of their role. But according to Dr.Jeffery Segal there are significant limitations to when a physician can refuse patient care. Is there an already established therapeutic relationship between doctor and patient? Segal confirms that  the doctor has nolegal obligation to treat under the common law　rule, unless there is an  establishedrelationship. However if the physician-patient relationship has been established, the opposite is true. Under such situations there are more defined terms upon which it may be terminated. Thus, it is important to figure out what establishes the relationship. Segal explains that the relationship has obviously formed once a patient has shown up for an appointment and has been examined or treated by the physician. However it can be formed other than by definitive actions. The reality according to Segal is that the more there is ‘medical’ contact between the patient and the doctor or the office, something as simple as filling out a history form or doing a basic evaluation, the more the individual can assume that they are a patient of the physician, and even thus the relationship is established.

　　Valerie Blakes states that, “apatient-physician relationship is generally formed when a physician affirmatively acts in a patient’s case by examining, diagnosing, treating, or agreeing to do so. Once the physician consensually enters into a relationship with a patient in any of these ways, a legal contract is formed in which the physician owes a duty to that patient to continue to treat or properly terminate the relationship”. On that basis one can agree that a physician-patient relationship had been established between Julia, Ms.Paul and the doctor. The surgeon would've done an examination of the patient’s condition before agreeing to perform the surgery and providing a medical quotation on that basis. That being true, then the next question is how can an existing physician-patient relationship be terminated and on what grounds would it not be considered a violation of the principles of medical ethics?

　　Dr.Segal believes that if therelationship is already established, it can only be annulled following the statutory and law requirements of the jurisdiction in order to prevent what is called actionable abandonment. This abandonment happens when ongoing patient care relations are terminated by the physician without sufficient advance notice for the patient to receive care elsewhere. As stated earlier by the SLMDA, the doctor in question did find an alternative for the patient. The reality is that if the physician wants to end the relationship, there is no legal requirement unless they are bound by a third party contract. Otherwise, a physician may decline to see a patient for any reason they think is justified although not without consequence. Anything that the doctor believes violates the Standard of Care, such as patient non compliance or bad behavior may result in their refusal to be involved in care. A physician can decline to provide personal religious beliefs like conducting an abortion.

　　Certainly, it is more difficultfor a doctor to terminate a relationship with a patient, especially if the patient does not wish it to end. According to Lois Margaret Nora, “A patient should be dismissed from a physician’s practice only for good reasons and after adequate notice and identification of an alternative care provider. Legally, if a physician does not properly release a patient from his or her practice, the physician may be found liable for patient abandonment.”. So, was the surgeon’s purported reason in our case justifiable grounds for patient dismissal? Was there adequate notice? Was social media a deal breaker or was it the physician’s hurt feelings? Whilst I personally don’t believe that the surgeon’s apparent reason was good enough, I understand the relativity of feelings and nuances. What's valid to someone else may be nonsensical to me and vice versa.

　　Perhaps an area not muchconsidered is how the physician’s personal feelings surrounding the patient-physician relation may affect that relationship and possibly impede the effective fulfillment of their medical care duties. The doctor’s emotional well-being must be considered too. No one would want a surgeon with emotional grievances and contempt, to operate on themselves, let alone their child. Though some might consider it unprofessionalism, others might argue that the doctor is doing what is in their best interest and that of their private practice. The negative press received as a result however, certainly did not work favorably for them. Nevertheless, the fact that the doctor provided an alternative showed that she acted in the best interest of the patient. Though the mother was initially fearful as she thought that a more considerable price would have to be paid to conduct the procedure overseas, she was later rest assured by another physician that the surgery could be performed on island.

　　Although it is certain that Juliawas not the intended target of the crime, she was ultimately a victim and along with her mother, had to pay the ultimate price. It is sad to note that there was more online outrage over the medical fees than over the criminal activity resulting in the outcome itself. Whilst many may disagree with the doctor’s decision, the doctor is well within their right to refuse to treat a patient once special considerations are made as in this case, making sure that alternative medical care options are available to the patient. As callous and unprofessional as it may appear, the doctor’s injured emotional well-being, although not often considered, may have well been the dealbreaker. And without direct testimony and more personal insight, no one can invalidate those feelings.

*References 

1. Calls for a doctor’s licence to be revoked. Accessed on October 28 2024 from https://thevoiceslu.com/2024/10/calls-for-doctors-license-to-be-revoked/

2. Haddad LM, Geiger RA. Nursing Ethical Considerations. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526054/#

3. Homicides decrease: Police reveal 6,758 Homicides decrease: Police reveal 6,758 crimes in 2024. Sharefil Gaillard. August 29, 2024. Accessed on October 25 2024 fromhttps://stlucia.loopnews.com/content/homicides-decrease-police-reveal-6758-crimes-2024

4. The four principles of medical ethics. Posted 08/02/2024. Updated 08/05/24. Accessed on October 25 2024 from https://www.medicalprotection.org/uk/articles /essential-learning-law-and-ethics

5. Law, ethics, and the clinical neurologist. Lois Margaret Nora Handbook of Clinical Neurology, 2013 Volume 118 Pages 63-78 https://doi.org/10.1016/B978-0-444 -53501-6.00005-6 Accessed on October 29th from https://www.sciencedirect .com/topics/medicine-and-dentistry/beneficence#:~:text=Beneficence%20is%20the%20ethical%20duty,in%20the%20patient's%20best%20interest.

6. Mom upset surgeon declines 7-year-old girl's facial surgery. Sharefil Gaillard October 22, 2024 Accessed on October 25,2024 from https://stlucia.loopnews.com/content/ mom-upset-surgeon-declines-7-year-old-girls-facial-surgery

7. Six-Year-Old Recovering From Gunshot Injuries. Keryn Nelson. October 22 2024. Accessed on October 28 2024 from https://stluciatimes.com/166663/2024/ 10/six-year-old-recovering-from-gunshot

8. SLMDA responds to situation with young girl's facial surgery. Sharefil Gaillard October 24, 2024. Accessed on October 31 2024 from https://stlucia.loopnews.com /content/slmda-responds-situation-young-girls-facial-surgery

9. When Can You Refuse to Treat a Patient? Jeffrey Segal, MD, JD. December 1, 2021. Accessed on October 25 2024 from https://medicaljustice.com/blog/when-can -you-refuse-to-treat-a-patient/

10. When Is a Patient-Physician Relationship Established? Valarie Blake, JD, MA. Accessed on October 29 2024 from Virtual Mentor. 2012;14(5):403-406. doi: 10.1001/virtualmentor.2012.14.5.hlaw1-1205.