Our story about Helen Carter, the Worcester primary care doctor no longer accepting new patients who are obese, drew emotional comments across the spectrum. They ranged from totally supportive ("The doctor should be free to make her own choices...") to outraged ("This is the most insensitive, hateful thing I've ever read").
Carter, an internist for 20 years, told me she decided to institute her no-new-obsese-patient policy primarily because a physician in her practice had been seriously injured pulling out the exam table foot rest for a 280-pound patient. Carter said her new policy (which essentially applies to anyone who is obese and over 200 pounds, or someone with a BMI over 30) is a way to avoid further injuries to providers and the subsequent loss of productivity. She also said her actions are not discriminatory because obese patients in her region have access to alternative providers, notably the weight loss center at UMass Memorial which offers tailored programs for the overweight and obese including nutrition, exercise, psychological counseling and surgical options.
(Here's video from Carter of a "real patient and a medical assistant" demonstrating how people can get injured in the health care profession.)
(And this is the original WCVB-TV report which focuses on an obese Shrewsbury patient seeking care who was turned away by Carter.)
The significance of a lone primary care doctor in central Massachusetts refusing to treat a few very fat people may be negligible. But what if it's the start of a trend with more and more internists refusing to treating the 35 percent of American adults who are now obese?
As one reader commented: "I am reminded of the early days of the AIDS pandemic, when some clinicians did not want to treat people with HIV, sometimes saying, at least for gay men, that it was the patient's "irresponsible and reckless behavior" that led the patient becoming infected. I find this deeply troubling and unethical."
Indeed, what if doctors increasingly cherry-pick patients, turning away people for conditions linked to less-than-healthy behavior? ("Lung cancer from smoking? Cirrhosis caused by alcohol abuse? A head injury from riding without a bicycle or motorcycle helmet? Injuries from a bungee jump?" suggested another reader.) Already, some doctors are refusing to treat children whose parents refuse to vaccinate them. Where do you draw the line?
For some clarity, I called a professional. Daniel Wikler, Ph.D. is a Professor of Ethics and Population Health in the Dept. of Global Health & Population at Harvard's School of Public Health. Here, edited and condensed, are my top 5 takeaways from our conversation. (A caveat: Wikler has never spoken to Dr. Carter so his thoughts are simply based on what he's read about her.)
1. Doctors don't have to take patients unless there's an emergency, but...
There's no law that says a private physician must accept a new patient, however, Wikler said: "Primary care means you take care of people with a wide range of problems." The fact that she's not a specialist in obesity-related matters and that there are experts nearby doesn't justify her actions, he said. "Should all primary care docs shunt their patients to specialists?" he said. Even if she can't treat every aspect of the patient's condition, "Certainly a primary care doc can treat many of the problems," he said.
2. Making Things Worse
Doctors' jobs are to help people. "The fatter you are, the more help you need," Wikler said. Presumably, Carter is committed to the well-being of these people, he said, and should offer whatever care she can to help them limit the damage their obesity has caused or at least help them prevent more damage. "To simply say 'I've reached the limit with you,' it's a death sentence," he said, or at least it could put patients in peril by creating barriers to care for those who may need it most. (For the record, Carter said she did not dismiss any of her current patients who are obese. And, she said, her new policy has motivated some of them to lose weight.)
3. What if everyone did it?
In some states nearly half the population is overweight or obese. And by 2030 the national obesity rate is forecast to rise to 42 percent. If doctors in states around the nation followed Carter's lead, that would mean a lot of heavy, uncared-for patients. "Do we think it's O.K. for doctors to stop treating half the patients in their state?" Wikler said.
4. What Happened To Compassion?
Nobody wants to be fat. But people still have a visceral reaction to the obese, Wikler said, "It's one of the seven deadly sins, gluttony." But doctors, at least, should be on the same side as their patients. Losing weight and keeping it off is extremely hard. He offered this:
Which is more difficult A or B?
A. Putting a human being on the moon.
B. Coming up with a diet plan that enables most people on the plan to lose substantial amounts of weight and keep it off.
You know the answer. Indeed such a diet plan doesn't exist.
5. Personal responsibility is complicated
Wikler writes a great deal about personal responsibility and how it relates to health care. Increasingly, the notion that we have control over our own health and should either be rewarded or penalized for our "good" or "bad" health-related behavior is central to the debate on medical costs, employer wellness programs, insurance coverage and other facets of health care delivery. But personal responsibility — and the idea that our own behavior is the single greatest determining factor in our health — is not as clear-cut as it may seem.
Wikler cited this example: Last year, Governor Jan Brewer of Arizona proposed a "fat fee" — a surcharge on Medicaid patients who were overweight. The rationale for the added charge was that the state was paying medical bills for these people's bad behavior. But, Wikler said, "each of us takes risks" concerning our health. He wondered whether or not Brewer ever played tennis outside, risking skin cancer? Or, he asked, does she drive too much and risk a road accident? "Each of us takes some risks, it's just that the obese wear theirs in a way that is unavoidable to see. For many of us, the risks we take are invisible."
This program aired on September 4, 2012. The audio for this program is not available.