The effect of patients' noncompliance on their surgeons' obligations.

Professional oaths and codes do not establish a firm basis for the obligation to treat all patients and they provide little or no clear guidance about whether patient nonadherence exempts a physician from a longstanding and still prevalent tradition in surgery supports a strong obligation to one's established patients. A personal belief in an obligation to serve those less fortunate or even less compliant could support sustained treatment and special assistance to a nonadherent patient. A collective, professional, objective, informed decision to exclude a patient who is highly likely to be nonadherent or incapable of adherence from the benefit of a scarce resource, such as a human organ, is defensible and appropriate. A surgeon's decision to deny care to an established but nonadherent patient is much less so. Adherence is as dependent on physician attitude, skill, and behavior as it is on patients' nonadherence. To the degree that it reflects less than competent management of this prevalent problem, it can be considered an error or complication that makes most surgeons feel even more obliged to mitigate or rectify the problem. This article describes the almost ubiquitous phenomenon of nonadherence; a way to reconceptualize noncompliance; and practical steps that can help predict, prevent, identify, and manage it. It is hoped that this helps surgeons reduce the frequency of nonadherence, make dealing with it less onerous, and consequently achieve better outcomes. It is reasonable to think about nonadherence in terms of three roles. The surgeon's role is to make the patient's choice informed, to be aware of the risk factors for nonadherence, and not make adherence any more difficult than it has to be. The patient's role is to make choices between value-laden alternatives. Society's role is equitably to distribute scarce medical resources to patients who can and want to adhere to the necessary regimen to benefit from them.