HLTH 6405 Week 11 No-Show Rule Applied Ethics Paper Example

Applied Ethics Paper: A Health Center's Three-Missed-Appointments Dismissal Rule Serves Most Patients and Predictably Excludes Some, and It Should Be Replaced With a Scheduling Restriction That Keeps Every Patient in Care

Student Name

Walden University

HLTH 6405: Ethics and Social Justice

Instructor Name

Month Day, Year

Applied Ethics Paper: A Health Center's Three-Missed-Appointments Dismissal Rule Serves Most Patients and Predictably Excludes Some, and It Should Be Replaced With a Scheduling Restriction That Keeps Every Patient in Care

The Case

Eastview Community Health Center, a composite clinic receiving federal health center funding, has a written policy: a patient who misses three scheduled primary care appointments without notice within 12 months is discharged from the practice and must find care elsewhere. The policy was adopted because missed appointments leave slots empty while other patients wait weeks to be seen. Staff report that it works: no-show rates fell after it began. A patient advocate on the center's board now asks whether the policy should stay.

Both answers are defensible. Keeping the rule protects timely access for the many patients who keep their appointments. Ending it protects the minority who miss appointments, often for reasons outside their control. This paper resolves the case in favor of replacing the dismissal rule and holds that answer against the strongest objections.

The Framework

The analysis uses a public health ethics framework designed for programs rather than single encounters. Kass (2001) asks what a program aims to achieve, whether the evidence shows it gets there, who carries its costs, whether those costs can be reduced and whether it is run fairly. Childress et al. (2002) add that when one moral consideration overrides another, the override should be effective, proportional, necessary and the least infringing option available. A health center's scheduling rule is exactly the kind of program-level decision these frameworks address.

What the Evidence Shows About Dismissal Policies

A retrospective study of 158,192 patients cared for by 182 primary care physicians across 16 clinics in eastern Massachusetts from 2013 to 2017 found 536 formal terminations of the patient relationship (Groisser et al., 2022). The most common cause, in 38% of terminations, was missed appointments, with some physicians and clinics enforcing a policy of dismissal after three no-shows. Terminations were not evenly distributed: age, race and ethnicity, education, relationship status, employment status and insurance type independently predicted them, and patients unemployed because of disability had more than nine times the odds of termination of patients employed full time. At chart review, 38% of terminated patients had no documented new primary care physician.

Applying the Framework

Goal and Effectiveness

The policy's goal, timely access for patients who keep appointments, is legitimate. Staff report fewer no-shows since the policy began, but the center has not separated the policy's effect from other changes, and part of the drop may simply reflect the removal of patients who miss appointments.

Burdens and Who Bears Them

The burden falls on discharged patients, who lose their medical home. The Massachusetts findings suggest that burden is likely to fall disproportionately on patients with disabilities, unstable employment or public insurance, groups whose missed appointments often reflect transportation, work schedules or health crises rather than indifference (Groisser et al., 2022). Losing a primary care home can mean losing medication management and preventive care, and more than a third of terminated patients in that study had no documented new physician.

Necessity and Least Infringement

The decisive question is whether dismissal is necessary to protect access, or whether a less burdensome rule could achieve most of the same benefit. Several alternatives exist. A patient with repeated no-shows can be restricted to same-day or open-access appointments, so that the patient is seen only when able to come and no slot is held empty in advance. Reminder calls or texts and outreach to ask why appointments were missed can address barriers such as transportation. Scheduling that overbooks predictably vacant slots can recover lost capacity. These measures protect other patients' access while keeping the patient in care.

Fair Implementation

A rule that predictably falls hardest on patients with disabilities and unstable circumstances raises a justice concern even if it is applied identically to everyone. Public health ethics asks programs not only to avoid unfair burdens but, at times, to reduce existing injustice (Kass, 2001). A professional code for health care executives likewise directs leaders to work to support access to health care services for all people and to establish safeguards against discriminatory organizational practices (American College of Healthcare Executives [ACHE], 2025).

The Resolution

Eastview should replace discharge after three missed appointments with a tiered response: an outreach call after the second missed appointment to identify barriers, and after the third, a temporary restriction to same-day appointments for six months, with the patient remaining a patient of the center. Dismissal should be reserved for conduct such as threats or violence, which the no-show rule was never meant to address.

Holding the Resolution Under Pressure

Objection 1: The restriction will not deter no-shows as well as dismissal. Perhaps not. But deterrence by dismissal works partly by removing patients from the count, which is a burden, not a benefit. The goal is access for others, and same-day restriction protects that goal by ensuring no advance slot is wasted.

Objection 2: Patients who keep appointments are treated unfairly when others waste slots. Their interest is in timely access, and the replacement rule protects it. Fairness to them does not require removing others from care when a less burdensome means exists.

Objection 3: The center cannot afford outreach. Outreach calls after a second missed visit are inexpensive compared with the clinical and financial costs of patients returning through emergency departments, though the center should measure this rather than assume it.

Objection 4: Some patients will never change. For them, the same-day restriction becomes permanent, which still keeps them in care and keeps advance slots open.

What Would Change the Answer

If same-day access could not be offered because of staffing, or if evidence at Eastview showed that the restriction failed to protect other patients' access, the case for a stricter rule would strengthen. Even then, the least infringing option would be a temporary suspension with a guaranteed path back, not discharge without follow-up.

Conclusion

The three-missed-appointments rule serves a legitimate goal by an unnecessarily harsh means. Replacing dismissal with outreach and a same-day restriction protects the access of patients who keep their appointments while keeping in care the patients most likely to be harmed by losing it.

References

American College of Healthcare Executives. (2025). ACHE code of ethics. https://www.ache.org/about-ache/our-story/our-commitments/ethics/ache-code-of-ethics

Childress, J. F., Faden, R. R., Gaare, R. D., Gostin, L. O., Kahn, J., Bonnie, R. J., Kass, N. E., Mastroianni, A. C., Moreno, J. D., & Nieburg, P. (2002). Public health ethics: Mapping the terrain. Journal of Law, Medicine and Ethics, 30(2), 170-178. https://doi.org/10.1111/j.1748-720X.2002.tb00384.x

Groisser, A. R., Reyes Nieva, H., Ruan, E., Wright, A., & Schiff, G. D. (2022). Terminations in primary care: A retrospective observational study of 16 primary care clinics. Journal of General Internal Medicine, 37(3), 548-555. https://doi.org/10.1007/s11606-021-06793-7

Kass, N. E. (2001). An ethics framework for public health. American Journal of Public Health, 91(11), 1776-1782. https://doi.org/10.2105/AJPH.91.11.1776