The problem of selective refusals and “weaponized vulnerability:” When patients leverage medical vulnerability against clinician obligations to care to coerce inappropriate accommodations.

Meera Sury, MD MTS – Clinical Fellow, Pulmonology, Critical Care, and Sleep, University of Minnesota

Abstract: Historically, asymmetry in power between patients and clinicians primarily posed risks to patients. However, progress on respecting patient autonomy has led to a kind of hazard to clinicians caused by obligations on clinicians to care for and prevent harm to patients, while respecting patient autonomy.
A different kind of asymmetry may arise when patients threaten to allow avoidable harms to happen to themselves, usually by selectively refusing to participate in routine treatment, as a way to coerce inappropriate accommodations by treating clinicians. Usually, these selective refusals cannot be resolved with communication or education, because the goal of the refusal is not related to treatment, but rather designed to coerce clinician behaviors and gain accommodations unrelated to their treatment goals.
Since clinicians have an obligation to care for and prevent avoidable harm to vulnerable patients, they are caught in a dilemma of whether to provide inappropriate accommodations to the patient to purchase patient participation in their own treatment, or to refuse the accommodation, and honor the patient’s selective refusal even though it may lead to avoidable harms that are also known to be inconsistent with the patient’s own treatment goals.
Harms caused by selective refusals and weaponized vulnerability include harm to clinicians’ professional integrity, and harms that follow from suboptimal care and inefficient use of staff resources. Nurses are particularly vulnerable to this problem. This session will begin describing features of the problem that cause ethical conflict, and propose solutions to mitigate harms to both patients and clinicians.

Keywords: Clinical Ethics, Patient Autonomy, Professionalism