Opinion : Right to refuse treatment

Submitted as part of my medical ethics class:

When a physician is providing treatment to a patient, the goal is generally to make the patient better. A physician will typically use any means at their disposal and a good doctor will never give up on a patient. Yet sometimes the patient may want to give up on treatment themselves. Just as it has been argued that a patient has autonomy to choose the treatment option that they feel is best (even if against the physician's wishes), we must also consider that the patients can choose no treatment as an option. It may seem counterintuitive that a person would deny even a slight possibility of recovery, but there are many reasons that a patient may choose to for go treatment.

Reasons for denying treatment vary from person to person, and may involve good or bad decisions from an ethics point of view. Reasons may include fear of unpleasant side effects, religious or moral objections, and simply personal preference if the positive outcome is remote. These are all good objections and should be honored by the physician. Physicians should recognize that sometimes palliative care is the best option and should cease more conventional treatments in terminal cases. Another reason for treatment refusal is financial or economic concerns. These reasons are an unfortunate reality in our profit-driven capitalist health care system and warrant a separate discussion from this one. Another set of reasons includes the patients refusing care because of fear, duress or the influence of others, their ignorance of the options or out of an irrational state of mind. These options are not acceptable for a physician and care needs to be taken that they do not cause bad outcomes.

Avoiding the reason of irrational refusal or any irrational decision can be a serious problem for physicians. Most physicians are in a bad place to make judgments about a patient’s capacity for decision, and their can be a lot of mitigating factors. A perfectly competent person who was just told they have a serious disease may be devastated and may instantly become irrational. Letting patients take time to think about a decision (at least 1 day) is a good idea in general but not possible in all cases. It is also hard to tell if the irrational decision may be caused by an underlying problem such as ignorance of the subject (which can be fixed if the physician embraces their role as an educator) or a mental illness. The mental illness problem is especially serious if it is separate from but interferes with the treatment of an illness such as cancer.

The options for a physician in the case of irrational decisions come down to whether the patient can be brought to a rational state of mind or simply taking the authority of autonomy away from them. Removing a patient’s autonomy and treating them against their will is an extreme case and should only be done if the patient is clearly not able to comprehend their situation and the treatment has an estimated positive outcome of at least 50%. All attempts must be made to educate the patient but the patient’s comprehension must be tested by having them explain their situation and the outcomes in their own words. If they are unable to demonstrate comprehension and continue to refuse treatment against good odds of recovery, they should be referred to a mental health professional for an evaluation. If the evaluation comes back that they are mentally incompetent, then a physician should make the treatment decisions for this individual. If a psychology evaluation comes back negative, than the patient’s wish must be honored, as long as the sign some sort of waiver absolving the physician of outcome responsibility. A patient always has the right to refuse treatment unless it can be shown that they are not mentally competent.