During the years I have been talking to doctors about medical ethics, I have often heard it said that when push comes to shove, the rights dice are loaded in favour of patients. All this talk of patient autonomy is all very well but what about the autonomy of doctors? What about our rights? With the bathwater of paternalism has surely gone the baby of independent clinicianship. It has been quite a fall—this is a lament I often hear—from demigods to handmaidens in the lurch of a single generation. If doctors are obliged, on pain of retribution from the General Medical Council, to show respect, why do increasing numbers of patients feel no such corresponding duty?

Nowhere are these things more exposed than when it comes to treating abusive, menacing, or even violent patients, nowhere is the apparent asymmetry between patient freedoms and doctors’ duties more acutely in evidence. So how should doctors proceed in the face of a menacing or abusive patient?

Because patients have certain kinds of rights to clinically indicated treatment it does not follow that any individual doctor has a duty to provide it, irrespective of any personal threat. To couch this again in the language of rights: doctors, like the rest of us, have a right to go about their work unmolested—that is to say, their physical security has to be ensured before they can be asked to provide treatment. If a respect for patient autonomy can be boiled down to a core legal prohibition against an invasion of bodily integrity—which is, after all, what consent renders lawful—then doctors’ rights here are equivalent.

If assault is the distant extreme, nearer at hand are the greyer zones of incivility, rudeness, hostility, aggression, prejudice, and direct abuse. Assuming the physical security of doctors has been vouchsafed, should any of this be tolerated?

Two things come to mind: first to what extent can the behaviour reasonably be traced to the patient’s underlying clinical condition; second, how urgent is the need for treatment? Where for example, violent or abusive behaviour is the expression of an underlying disorder, arrangements should be made to provide treatment at a time and in a setting where the security of the treating staff can be assured. In some cases of course the behaviour is not linked to an underlying pathology: some people can be, for whatever reason, just unpleasant. Here things are slightly different. Where treatment is immediately necessary it should be provided, but only in so far as the safety of staff –and of other patients—can be secured. To push it to extremes, if a very sick patient wanders into A&E wielding a handgun, the first thing to do is to call the police; treatment will have to wait. Where the treatment is not immediately necessary, where it is routine or elective, in my view abusive behaviour need not be tolerated. Either the patient returns to civility or any treatment will have to be provided at a time and a place where the rights of health staff—and of other patients—can be respected. And this might mean that some of the ordinary assumptions of medical care might be foregone: that the consultation might have to take place in the presence of a security guard, that it might have to be at a time, and in a place, less convenient for the patient.

To précis, abusive behaviour may lead to the denial of treatment in the ordinary way where the behaviour is likely to:

• Undermine the likelihood of providing the desired clinical benefit
• Present a risk of harm to those providing treatment
• Harm other patients
• Result in damage to property

It might be because I am getting older, and my ear is better attuned, but I hear complaints more and more often about a general decline in civility. Given the impossibility of finding a control, hard data will remain elusive, but the anecdotal evidence is there to be heard. Hand in hand with this—either as cause or correlation, depending upon who is talking—has gone a rise in rights-speak. We all know our rights it would seem but we are in danger of forgetting our manners.

Rights give us certain powers and certain immunities and they are an absolutely necessary part of our lives: without enforceable rights, power will run unchecked. There is simply no point being nostalgic for lost eras of noblesse oblige. But necessary as rights are to a reasonable life, they are not sufficient. A life pared down to the bones of its rights—precisely those bones exposed by violent and abusive patients—is an arid life of claim and counter-claim. For medical care to flourish trust is needed, and that requires a very different kind of relationship. And nurturing trust between doctors and patients might just be among the biggest challenges medicine will face in the coming years.

Julian Sheather is ethics manager, BMA. The views he expresses in his blog posts are entirely his own.