Nonabandonment: An Old Obligation Revisited

In medical ethics, the term “abandonment” has customarily meant unilateral withdrawal by a physician from a patient's care without first formally transferring that care to another qualified physician who is acceptable to the patient. Abandonment means leaving the patient without care. As such, abandonment has been universally condemned as a serious and punishable infraction of both the legal and ethical obligations that physicians owe patients. Its converse, nonabandonment, is therefore a fundamental ethical obligation of physicians once patient and physician mutually consent to enter into a relationship.

In this issue, Quill and Cassel [1] propose to alter this traditional interpretation by expanding the obligation of nonabandonment in an idiosyncratic and problematic way. They believe that this is necessary to make medical care more humane, personalized, and ethically responsive. They would subsume under the rubric of nonabandonment a large part of medical ethics, including care of the whole person, attention to the details of each patient's life and illness, and integration of insights from so-called alternative theories of ethics now being discussed as antidotes to the excessive “abstractness” of principle-based ethics. This enlarged concept of nonabandonment, they argue, entails the physician's long-term commitment to care, especially when patients are terminally or chronically ill.

There is little to quarrel with in Quill and Cassel's call for medical care that is more ethically responsive to patient needs and that makes satisfaction of those needs a moral obligation. Many educators, clinicians, ethicists, behavioral scientists, and patients have justifiably lamented the neglect of these needs in contemporary care. The central questions are whether all the neglected dimensions of care can be subsumed under the rubric of nonabandonment, whether that rubric is sufficient as a primary moral imperative, and whether it helps in a practical or theoretical way to advance the kind of care that Quill, …