As a part-time instructor in a large university clinic, you are overseeing the residents as they examine new patients for admission. While awaiting his initial examination, a burly adolescent boy suddenly lapses into a grand mal epileptic seizure. You hear the commotion and clear the area so that the patient will not injure himself. Once the seizure concludes, your discussion with him and review of his medical history reveals that he is often noncompliant in taking his anticonvulsant medication.

Unfortunately, before you have the opportunity to discuss your concern with his mother, your resident tells her that her son cannot be treated at the clinic because of epilepsy. The mother becomes irritated and threatens to “report the clinic for discrimination.” Is she justified? Do you have a legal and ethical right to refuse this patient for treatment? If so, on what grounds would you reject him?

Establishment of the doctor-patient relationship is a contract that begins by voluntary and mutual consent between the doctor and the patient (or the patient’s parent or guardian). The provider’s consent can be expressed or implied. Physicians, for example, can establish intent simply by examining a patient and prescribing specific therapy. In orthodontics, the relationship might not occur until a thorough examination has been conducted, diagnostic records are produced, and a treatment plan is discussed with the patient. If no prior relationship between doctor and patient exists, the doctor is entitled to a “no duty rule,” which permits him to refrain from becoming involved in the patient’s care. The exception is in the case of an emergency, in which the practitioner is obligated to arrange for the patient’s care. Whether the treatment is elective or emergency, however, the patient can decide that the proposed treatment options are unacceptable and thus decline therapy.

Two important acts of legislation have affected the “no duty rule.” The first is Section 504 of the Capital Rehabilitation Act of 1973, which prohibits rejection of a person for medical care based solely on disability if the provider or providing institution receives federal sources of financial assistance. The second is the Americans with Disabilities Act (ADA) of 1990, which prohibits denial of health care for disabled or medically compromised patients as long as risks to persons in the facility can be eliminated by reasonable modification of the facility. This legislation is associated with the responsibility of a dentist to treat HIV seropositive patients.

Violations of either law can initiate legal action. But what are the ethical considerations involving this issue?

The AAO’s Principles of Ethics and Professional Code of Conduct, Section VI, states, “Members may exercise discretion in selecting a patient into their practice, provided they shall not refuse to accept the patient because of the patient’s race, creed, color, sex, national origin, disability, HIV seropositivity status or other legally recognized protected class.”

Most private practitioners do not accept fee reimbursement by federal funding, but dental schools and hospital clinics often do. Although a “contract” between the clinic and the patient at a screening evaluation might not yet have been established, it is considered discriminatory for a dental school or hospital faculty to reject a patient based on a disability. It also would be unwise to reject a patient from your private practice if the reason for your rejection is solely based on discrimination, including any of the reasons listed above in the AAO code.

From an ethical perspective, your decision to decline a patient for care must be based on reasons that do not imply discrimination: ie, reasons of universal application. You should offer assistance in identifying a possible alternative provider. Finally, your good will and your authentic intent displayed during this communication should be thoroughly documented in writing, ideally in both the patient’s treatment record and in a subsequent letter to the patient.