Patient Solicitation in Nephrology Practices: Ethical Boundaries and Patient Autonomy

Doctor-patient covenant and the complexity of modern nephrology practices

The central tenet of our medical practice is the duty to prioritize the needs and interests of the patient, a commitment that stands apart from commercial interests and is rooted in the ethical principles of trust, beneficence, and non-maleficence. It is ultimately this commitment to the patient, above all else, and the sacredness of the patient-doctor relationship that should drive all decision-making by nephrologists on behalf of their patients. The evolving landscape of health care, with its practice consolidations, hospital system mergers, and proliferation of accountable care organizations (ACOs) and value-based care delivery models, presents complex ethical challenges, particularly as they relate to patient solicitation and care transitions. Historically, avoiding patient solicitation within the field of nephrology meant not interacting with another practice's patients with the intention of luring the patient away to one's own medical practice, especially in the setting of a dialysis center or hospital.

With recent changes in the health care landscape, more nuanced scenarios have arisen that require thoughtfulness to ensure that patient solicitation is not taking place and that decisions are made with the best interests of the patient in mind. For example, some important questions follow.

• ▸When a patient transfers into a dialysis center without an assigned nephrologist, should this patient automatically be assigned to the medical director, or should there be a fair and impartial process in which the patient is presented with a list of all available nephrologists at that dialysis center?

• ▸Similarly, if a hospitalized patient requires a nephrology consult, should the patient automatically be assigned to the nephrologist employed by the hospital, or should there be a fair and impartial process in which the patient is presented with a list of all available nephrologists at that hospital?

• ▸When a patient is admitted to a hospital in which the patient's regular nephrologist does not have privileges, what steps should be taken upon discharge to encourage the patient to return to follow up with their established nephrologist?

• ▸If a patient's medical practice participates in an ACO, should all referrals automatically occur amongst doctors who participate in that ACO, or should the patient be given options of other doctors who do not participate in the ACO?

• ▸Should patients be informed of financial relationships that referring nephrologists have with specific dialysis centers or vascular access centers? If the answer is yes, what is the proper way to disclose this information so that the patient is informed, but the disclosure does not also inadvertently present the appearance of impropriety when there is none?

• ▸If a nephrology practice dissolves or if a nephrologist leaves a practice, what is the optimal way for those patients to continue receiving their nephrology care?

These example scenarios risk compromising the ethical integrity central to our profession and may erode the trust that patients place in their health care practitioners. The questions demand careful consideration, as they vary in their ethical implications across different states and health care settings, highlighting the need for a nuanced understanding of these dilemmas and a steadfast commitment to ethical principles in patient care.

Principles-based approach

It is important to note that although the RPA position paper broadly discusses the aforementioned scenarios (1), detailed guidance on how to resolve these situations is not provided because the details of each situation are different, and there is no way to broadly mandate best practices for every individual case. Rather, the RPA's position paper emphasizes a principles-based approach to ethical dilemmas in nephrology, stressing the importance of patient autonomy and the right to informed decision-making. This approach should involve nephrologists, primary care physicians, and dialysis units working together to ensure that patients have access to transparent information and the freedom to choose the nephrologist who best meets their needs (Table 1).

Table 1

Roles of various stakeholders to help with seamless patient transitions

View Table

Central to this strategy is the equitable treatment by health care practitioners of patients, not as commodities but as individuals entitled to justice, autonomy, beneficence, and non-maleficence in their care. The RPA paper is a timely reminder of our duty to uphold these values, ensuring that patient-centered care remains at the heart of our practice.