The do’s and don’ts of upfront payments for medical treatment

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RoxanneMany private medical practitioners question their right to ask a patient to make an upfront payment for treatment. If a patient arrives at a busy general practitioner’s practice, can the receptionist request payment prior to the consultation? Is it ethical or legal to do so? asks attorney and legal advisor in the healthcare sector Roxann van Rugge for MedicalBrief.

The rules of the Health Professions Council of South Africa state that a doctor should always put the best interest of his or her patient before questions of payment.

Three ethical principles must be considered when asking for upfront payments: patient autonomy, beneficence and non-maleficence, and fairness or justice.

Ethical principles

Patient autonomy means that a patient has the right to be adequately informed of his or her medical condition and to make an informed decision based on the information given. A patient consulting his or her general practitioner has the right to be made aware of the practices payment policy prior to the consultation.

Patients are entitled to decide to join a medical aid scheme or to pay cash for their treatment and exercise their right to autonomy by accepting that they have to pay for their treatment according to the terms and conditions of the specific agreement with their doctor.

Simply put, the principles of beneficence and non-maleficence require a doctor to do good for their patients and not to harm them.

If the patient at the general practitioner’s practice decides that the consultation fee is too expensive and the doctor decides not to treat a patient as a result, the doctor must still act for the benefit of the patient and ensure that their health is not harmed by referring them to a colleague who may be more affordable.

It is also essential that all doctors treat their patients fairly or justly. Patients who cannot afford to pay in advance for their treatment should be treated fairly by taking into account their personal circumstances before a doctor decides whether or not to treat them.

The circumstances may justify a doctor refusing to treat a first-time patient who cannot afford to pay cash in advance, but it may be unfair to refuse to treat a regular patient who cannot afford to pay because of a temporary cash-flow problem. If a regular patient was unable to make payment mid-treatment, it would be unethical for a doctor to discontinue the treatment.

Essentially, a doctor may not abandon a patient on the grounds that the latter is unable to pay for treatment in advance without making alternative arrangements for treatment, however – except in emergencies or for unconstitutional reasons – doctors may legally accept or refuse patients as they wish.

If a patient belongs to a medical aid scheme and is told in advance that the doctor has contracted out of medical aid scheme rates, payment for the treatment will usually need to be made in advance and the balance recovered from the scheme.

In this situation it would be ethically justified for the doctor to refuse to treat the patient if the patient was not prepared to do so. In addition, if a patient does not belong to a medical aid scheme and is told that payment must be made in advance but is not willing to do so, the doctor can refuse to treat the patient.

Unjustifiable situations

There are situations where refusing to treat a patient who cannot afford to pay in advance is not considered ethically justified:

  • In a medical emergency where the patient needs to be stabilised and then referred to a public health facility or to a doctor who the patient can afford to consult – for example through a medical aid scheme.
  • When refusal to treat the patient is not linked to a referral to an appropriate public health facility or other facility, as it may constitute abandonment of the patient.
  • When a returning patient who has a good record of payments is temporarily short of money and requires ongoing treatment.

These situations do not satisfy the ethical principles because patients have no choice regarding their financial position and cannot exercise their right to autonomy.

They also fail to satisfy the principles of beneficence, non-maleficence and justice or fairness because the doctor is not “doing good” for the patient but is rather actively harming the patient, and not treating them fairly.

Whether or not it is ethically acceptable for doctors to require payment of fees before treatment depends on an interpretation of the ethical rules of the profession.

It is important to consider the circumstances of the doctor-patient relationship, the urgency of the patient’s need for treatment, and whether refusal to treat before payment would be regarded as abandonment of a patient.

* Roxann van Rugge is a BA LLB (Rhodes University) graduate and admitted attorney working as a legal advisor in the healthcare sector, including for the Dalmor Medical Administration Training Institute. Her practical experience in dealing with healthcare and medical practice issues has given her extensive knowledge of patient rights and medical ethics.


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